UPDATED MAY 2025: Due to budget and staffing constraints, we are no longer able to take new referrals for our Pathways Program. Please contact 211 for additional resources.
Referral is for
An adult
An adult with an appointed legal guardian
A child
Is the client aware of this Referral
Yes
No
Person Completing Form
Referring Agency
Type Of referral Agency
*
211 Referral Agency
Ambulance Service
Community Health Worker
Community Mental Health
Community Organization
County Human Service Office
Emergency Department
Health Plan
Home Health Agency
Hospital
Primary Care Practice
Self-referred
Specialty Care Practice
Phone Number
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
Email
example@example.com
What is the Best way to Reach you?
Phone
Fax
E-mail
Client Information
Full Name
*
Prefix
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Male
Female
Due Date (if Pregnant)
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Gratiot
Clinton
Montcalm
Phone Number
*
-
Area Code
Phone Number
E-mail
Race (check all that apply)
White or European American
Black or African American
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian &Other Pacific Islander
Other
Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Primary Spoken Language
English
Arabic
Bosnian
Burmese
Chinese
Farsi
French
Hindi
Hmong
Nepali
Spanish
Somali
SWahili
Vietnamese
Other
Insurance Type (check all that apply)
Medicaid or Healthy Michigan
Medicare
Medicare Advantage
Commercial
None
Other
Primary Doctor Name (or Pediatrician if referral is for a child)
Primary Doctor Phone Number
-
Area Code
Phone Number
Name of Practice
Number of Hospital Admissions in the past 12 Months
Chronic Health Conditions (check all that apply)
Addiction/ Substance Abuse
Anxiety
Arthritis
Asthma
COPD
Depression
Diabetes
High Blood Preasure
Hyperlipidemia
Stroke
Tobacco
Unsure
Other
Reason(s) For Referral
Adult Main Reason For Referral
Acess to Community Resources
Access to Behavioral Health Services
Access to Medical Provider
Chronic Conditions Management
Inappropriate ED use
Medication Concerns
Needs Medicaid Coverage
Pregnancy or Postpartum Support
Recent Hospitalization/Readmission Risk
Other Reasons for Adult Referral
Abuse/Neglect
Access to Behavioral Health Services (includes mental health/substance abuse)
Access to community Resources
Access to Medical Provider
Chronic conditions Management
Disability
Environmental Risk (mold, Lead, pests, etc.)
Inappropriate ED use
Medication Concerns
Needs Medicaid Coverage
Pregnancy or Postpartum Support
Recent Hospitalization/Readmission Risk
Other
Child Main Reason for Referral
Abuse/Neglect
Asthma
At risk of Dismissal From Medical Home
Developmental Delay (speach, language, hearing, vision,etc.)
Disability
Environmental Risk (mold,Lead, pests, etc.)
First Child
Missed Appointment(s)
Need appointment Remindersa
Need Immunizations up to date
Need Transportation foe Medical Appointments
Access to Medical Provider
Needs Medicaid Coverage
New Patient Intro to CHAP
Patient Education
Other Reasons for Child Referral
Abuse/Neglect
Access to Community Resources
Access to Medical Provider
Asthma
At Risk of Dismissal from Medical Home
Access to Behavioral Health Services (includes mental Health/Substance abuse)
Developmental Delay (speech, language, hearing, vision, etc)
Disability
Environmental risk (mold, lead, pests, etc)
First Child
Inappropriate ED use
Missed Appointment(s)
Need Appointment Reminders
Need Immunizations Up to Date
Need transportation for Medical Appointments
Needs Medicaid Coverage
New Patient Intro to CHAP
Parent Education
Teen Parent
Other
Any Additional Information
Please provide any additional information regarding the reason for this referral that may be helpful in determining eligibility into our programs. Please explain any concerns you may have checked off.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Should be Empty: