Harris County Pathways Community HUB Client Referral

Harris County Pathways Community HUB Client Referral

Please note: ALL required questions (indicated with a * ) must be answered completely, or your referral will not be submitted.

Referral Consent*

Individual has given consent to share the below information with the Harris County Pathways Community HUB for the purpose of enrollment into the care coordination program.

Yes

Referral Eligibility*

Pregnant with behavioral health risk factors; lives in Harris County; receiving or eligible for Medicaid or is uninsured.

Postpartum with behavioral health risk factors; lives in Harris County; receiving or eligible for Medicaid or is uninsured.

Has a mental health diagnosis; lives in Harris County; receiving or eligible for Medicaid or is uninsured.

Has a substance use disorder; lives in Harris County; receiving or eligible for Medicaid or is uninsured.

Referral Source Information:

Name of Referring Agency*

Name of Referring Person*

Contact Number of Referring Person*

Phone

Referring Email*

How did you hear about us?*

New Client Information:

Enter the required information for the person you are referring to the Pathways Community HUB below

Client Type*

Adult (to include postpartum)

Pregnant

Client Name*

Date of Birth*

Street Address*

City*

State*

Select or enter value

ZIP Code*

Client Phone*

Phone

Client Email

Health Insurance ID Number (if applicable)

Race*

Select

Ethnicity*

Select

In order to best serve the client, please note if there are any language barriers to take into account for efficient communication: (if none use "N/A")*

Additional notes about referral

For Pregnant Referrals; please answer the following:

OB Provider

OB Phone

Due Date

Send me a copy of my responses

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