DHHS → Community Care for Social Support: COVID 19 Referral Form

Community Care for Social Support: COVID-19 Referral Form

Referral source information

Date (required)

Referral source name (required)

Relationship to client

Contact phone

Contact email (required)

Is immediate, same-day response needed, or response within 24 hours?

Client Information

Client name (required)

CDC Case # (if known)

Primary Phone (required)

Secondary Phone

Date of Birth

Anticipated end date of Isolation/quarantine

Reason for Referral (required)

How is this person or household affected by COVID-19? Include where and when they were tested, if they have symptoms, and, if they’ve had close contact with a person confirmed to have COVID-19, describe their last interaction with that person.

Address (required)

City/Town (required)

State

ZIP Code

Race

Ethnicity

Number of Household Members

Please include # of household members known to have COVID-19 and # who are close contacts.

Preferred Language in Home (required)

For any language other than English, please share the person’s nationality to ensure accurate translation and interpretation services.

Other information

Include any other important information, such as whether the person is at high risk of COVID due to their living situation, job, or health.