Care Intake/Referral Form

Language

Greater Health Now (GHN) serves Asotin, Benton, Columbia, Franklin, Garfield, Kittitas, Walla Walla, Whitman, Yakima Counties, and the Yakama Nation. We are an independent nonprofit organization committed to building vibrant and healthy communities. We partner with local organizations to help coordinate care that addresses real needs, and helps more people thrive.

If you are experiencing an emergency, please call 911 immediately.

Client Information

Client First (Given) Name

Client Last (Family) Name

Preferred Name

Client Date of Birth

Gender

Preferred Language

Other language (if "Other" selected above)

Email Address

Best Contact Number

Extension

Contact Number Type

Is it ok to leave a detailed message at this number?

In general, what is the best time of day to reach you?

Address

Street Line 1

Street Line 2

City

County

State

Zip Code

Race/Ethnicities

Referral Source

Type of entity making referral

Referral Source Organization

Referring person (first and last name)

Referral Source Phone Number

Referral Source Email

Preferred organization for care coordination (if any)

Other referral needs

Consent

By submitting this referral form, you confirm that the prospective client has provided informed consent to share the information included here with the HUB for the purpose of determining eligibility and potential enrollment in care coordination services.

Submitting a referral does not guarantee eligibility or placement. All referrals are reviewed based on program criteria and the availability of resources. Referrals with incomplete or limited information may be delayed or deemed ineligible.

All information will be handled in accordance with applicable privacy laws and regulations, including HIPAA where applicable.

Consent I have read and understand the information above

Care Intake/Referral Form

Please correct the following errors

Client Information

Referral Source

Social and Health Barriers

Other referral needs

Consent

Verification