New Referral
Client Contact Information*
Select all categories that apply to this client's needs (at least one required) *
Basic Needs
Employment & Education
Family & Social
Safety
Healthcare
Behavioral Health
Other
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 the Health Insurance Portability and Accountability Act (HIPAA), where applicable.
I have read and understand the information above