Request for RH Services

Community Member Referral Form推荐表
RaisingHealth (formerly known as Academy of Public Health Services) is a not for-profit health service organization with a triple aim to identify barriers to health and wellness in underserved immigrant communities; coordinate truly needed primary care with social assistance; and deliver care with dignity and empathy to marginalized New Yorkers.

安服心是一个非营利性卫生服务组织，其三重目标是确定服务不足的移民社区的健康障碍；将真正需要的初级保健与社会援助相协调；为边缘化的纽约人提供有尊严和同情心的护理。

Address: 5306 3rd Ave, 2nd Floor, Brooklyn, NY 11220

Office Hours: Tuesday - Saturday 10:00am-6:00pm

Phone Number: (212) 256-9036

地址： 5306 3rd Ave, 2nd Floor, Brooklyn, NY 11220

办公时间：周二至周六 10:00am-6:00pm

电话号码：(212) 256-9036
Referring Agency Information
Follow up
Follow up Date

MonthDayYear
Date
Follow up call Made by
Assigned Case Manager
Referring Agency推荐机构*
Agency Address 机构地址*
Agency Phone Number机构电话号码 *
Referrer's Full Name 推荐者姓名
Referrer's Email Address推荐者邮件地址
I First Name* 名 Last Name姓* grant permission for the release of the community member's personal information at their own request in order to obtain support services.授予社区成员根据自己的请求发布个人信息的许可，以获得支持服务。
Referrer's Signature 推荐人签名*

Clear
Community Member Information
Community Member Name

First NameLast Name
Date of Birth生日

Month 月Day 日Year 年
Phone Number 电话号码
Please enter a valid phone number.
Email Address电邮
Enter none@gmail.com if applicant does not have an email
Preferred contact method:首选联系方式

Phone call电话Text message短信E-mail电邮
Home Address 家庭地址
City城市:*

Street Address

Street Address Line 2

State / Province

Postal / Zip Code
State州:*

Street Address

Street Address Line 2

City

Zip Code
ZipCode邮编:*
Preferred language?首选语言*

Arabic العربيةEnglishSpanish EspañolCantonese 粤语Mandarin 国语Fujianese 福州话Toishanese 台山话
Gender性别*

Male男Female女Non-binary非二次元Prefer not to answer不愿回答
Ethnicity族裔*

Hispanic or Latino拉丁裔Non Hispanic-Latino非拉丁裔Unknown未知Prefer not to answer不愿回答
Race种族:*

African American/非裔美国人/AfroamericanaAmerican Indian/美印第安人/Indio AmericanoAsian/亚裔/AsiáticaNative Hawaiian & Other Pacific Islander /夏威夷原住民/其他太平洋岛国/ Nativa hawaiana y otra isleña del PacíficoWhite/白人/BlancaMixed Race/混种/Raza MixtaPrefer not to answer/不想回答/Prefiero no responderOther
Are they covered by Health Insurance?他们有健康保险吗？*

Yes是No否Not sure不确定
Community Health Services: Please Select the type of services that the community member is interested in being connected to. 社区健康服务：请选择社区成员感兴趣的类型：For further information, please contact: Lysna Paul, Manager of Community Health, at lysna@raisinghealth.org
English Classes: Please Select the type of services that the community member is interested in is interested in being connected to.英语课程：请选择社区成员感兴趣的服务：For further information, please contact Desiree Brown-Malta, Director of Programs, at desiree@raisinghealth.org
Community Building Programs: Please Select the type of services that the community member is interested in is interested in being connected to.社区安全项目：请选择社区成员感兴趣的类型：For further information, please contact Kanako Kawabe, Manager of Community Building at kanako@raisinghealth.org.
Additional Comments 额外评论
Please click “submit” to send referral 请点击“提交”发送推荐表
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Community Member Referral Form推荐表

Referring Agency Information

Community Member Information