Place Patient Label Here

Health Leads connects Rainbow Ambulatory Practice and Women’s Health Center patients with the basic resources they need to
be healthy. Please complete the form below so we can help connect you with services in your community. Thank you.
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Please check any that are true for you.
I want help getting healthy food for me and/or my family.

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I worry that my home is unhealthy, or that my family may become homeless.

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I have trouble paying my utility bills (gas, electric, phone).

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I want to apply for public benefits (e.g. food stamps, cash benefits, WIC, SSI/SSDI).

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My family needs diapers, clothing, car seats, furniture, other.

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I am having legal issues, such as eviction and divorce.

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I want help with transportation for clinic appointments, the pharmacy, and other
services.
I need help finding employment or job training.

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I want to find adult education classes (ESL, GED).

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I want to find childcare, afterschool programs, or summer camps for my children.
I want parenting resources for myself.

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I do not have any needs at this time.
If you checked any of the above, do you want help with these needs?

Yes

No

Your Name: _________________________ Preferred Language: __________________________
Phone : ____________________________ Best Time to Call: ____________________________
Referral to Health Leads—STAFF USE ONLY

Date: _________________

Staff Checklist:
1. Place a patient sticker on the top right corner of both copies and attach 3 labels.
2. PRINT Provider name and date clearly
3. Give patient carbon copy of screening and place original document in HL bin
4. Check Health Leads screening & referral outcome on the patient routing slip
Staff Notes:
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Patient Refused Service

Referring Provider: ______________________