• Bridges to Health Pathways Referral Form

    Bridges to Health Pathways Referral Form

  • Áqwłtpwisha Chúushna Referral Form

    Áqwłtpwisha Chúushna Referral Form

    Native Support program

  • All referrals should be sent: b2h@gorgehealthcouncil.org or faxed to 541-397-0004 or via form completed at www.cghealthcouncil.org/bridges-to-health

    *Referrals should be sent for households or individuals who have expressed interest in wanting to work with a Community Health Worker.  *Clients being referred must live in Hood River or Wasco County

  • COMMUNITY MEMBER/CLIENT BEING REFERRED

  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Contact Preference*
  • Primary spoken language*
  • Does the Client identify with a disability?
  • Is the Client houseless?
  • Is the client a veteran?

  • REFERRED BY

  • Format: (000) 000-0000.
  • Today’s Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Client acknowledges that they are being referred for services and understands that they will be contacted by the program?*

  • BRIDGES TO HEALTH PATHWAYS PROGRAM CRITERIA

  • To qualify for the program, the answer to questions 1 and 2 below must be ‘YES’

  • 1- Client is struggling to access resources on their own:*
  • 2- Client understands our CHW's support clients in understanding and accessing available services*
  • What kind of support feels most helpful to you in this moment?*

  • Phone#:541-705-2705 or email B2H@gorgehealthcouncil.org

    Bridges to Health Pathways Community HUB Referral Form- Updated April 2026

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