Referrals/Forms

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Evidence Based Programs Self Referral Form

Evidence-Based Program Self-Referral Form

Date (required)

First Name (required)

Last Name (required)

DOB (18+ only) - required

Phone Number (required)

Secondary Number

Address

Street Address Line 1 (required)

Street Address Line 2

City (required)

State (required)

Zip Code (required)

Email (required)

Which course are you interested in? (required)

- Select -Diabetes Prevention ProgramDiabetes Self Management ProgramChronic Disease Self Management ProgramTai Chi for ArthritisWalk with Ease

For the Lifestyle Change Program (Diabetes Prevention Program), please choose one of the options below: (required)

- Select -History of gestational diabetesFasting plasma glucose (100-125 mg/dL)Hemoglobin A1C (5.7%-6.4%)Pre-diabetes Risk Assessment Score of 5 or HigherNot applicable

For the Diabetes Self-Management Program, has a medical professional told you that you have diabetes? (required)

- Select -YesNoNot applicable

For the Chronic Disease Self-Management Program, has a medical professional told you that you have a chronic illness? (required)

- Select -YesNoNot applicable

For Tai Chi for Arthritis, (60 years of age or older AND one or more of the following) - required

- Select -Arthritis diagnosisRheumatic disease or related musculoskeletal conditionMild, moderate or sever joint involvement and back painAdult with higher risk of fallingNot applicable

For Walk with Ease (60 years of age or older AND must be able to be on your feet for at least 10 minutes without increased pain)) - required

- Select -Arthritis, diabetes, heart disease or other chronic disease diagnosisNot applicable

Who is your Primary Care Provider? (required)

What days of the week would work best for you to attend a class? (required)

What times of the day would work best for you to attend a class? (required)

Do you have any family members/friends that are also interested? (required)

How did you hear about the program? (required)

Have you ever had issues accessing or affording food that help control your diabetes or prediabetes? (required)

- Select -YesNo

Additional Comments?

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Children With Special Needs Program Referral Form

Children with Special Needs Programs Referral

Please choose one of the following programs: (required)

Child Find

Early Intervention

Preschool

Children and Youth with Special Healthcare Needs (CYSHCN)

Today's Date: (required)

Child's Name: (required)

Date of Birth: (required)

Sex: (required)

- Select -MaleFemale

Person Making Referral: (required)

Phone #: (required)

Parent/Guardian: (required)

Phone #: (required)

Mailing Address: (required)

City/Town (required)

State (required)

Zip Code (required)

School District:

- Select -Harrisville Central SchoolBeaver River Central SchoolLowville Academy Central SchoolCopenhagen Central SchoolSouth Lewis Central School

Language Used At Home: (required)

Child's Race:

Child's Ethnicity:

Primary Health Care Provider's Name: (required)

Medicaid Eligible?

Yes

Medicaid Number:

Insurance Co.

REASON FOR REFERRAL: [ICD-10 Code if applicable] (required)

Auto Qualifier? *FOR DOCTOR'S OFFICES ONLY*

- Select -YesNo

OTHER INFORMATION/DIRECTIONS TO HOME:

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Referrals/Forms

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Referrals/Forms

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