Bridges to Health Pathways Referral Form

Bridges to Health Pathways 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
Client or Parent/ Guardian Name*
Date of Birth*

MonthDayYear
Date
Phone #:*
Contact Preference*

PhoneTextEmail
Email
example@example.com
Do they currently have health insurance?*
Member ID?
Client's Physical Address*
Client info: Gender identity*
Primary spoken language*

EnglishSpanishOther:Other
Race/ Ethnic identity:
Does the Client identify with a disability?

YesNo
Is the Client houseless?

YesNo
Is the client a veteran?

YesNo
Household size
Client’s Primary Care Provider Name*
Clinic Name
REFERRED BY
Name*
Phone #*
Email
example@example.com
Today’s Date

MonthDayYear
Date
Agency/ School and your title*
Client acknowledges that they are being referred for services and understands that they will be contacted by the program?*

YESNO
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:*

YESNO
2- Client understands our CHW's support clients in understanding and accessing available services*

YesNo
What kind of support feels most helpful to you in this moment?*

Information about resourcesHelp to navigate local resourcesHelp me apply for housingAdvocationMental and Behavioral health supportShort term aid or assistanceSubstance Abuse ResourcesFind a Dental or Medical providerHelp filling out applicationsNot sure yet
Please complete the Additional Information box as thoroughly as possible. Include any details about the case that will help us determine how to assign the case. This helps us determine urgency, prioritize the case, and assign it to a Community Health Worker in a timely manner.*
Phone#:541-705-2705 or email B2H@gorgehealthcouncil.org

Bridges to Health Pathways Community HUB Referral Form- Updated January 2026
Should be Empty:

Bridges to Health Pathways Referral Form

Áqwłtpwisha Chúushna Referral Form

COMMUNITY MEMBER/CLIENT BEING REFERRED

REFERRED BY

BRIDGES TO HEALTH PATHWAYS PROGRAM CRITERIA