Community Health Worker Referral Form

Community Health Worker Referral Form — Form Fields

This healthcare template includes 11 fields. Clinicians refer patients to a community health worker for social determinants of health support and navigation. Free to customize and use on ZenBuild.

• Referring Provider Name (text, required)
• Provider Email (email, required)
• Patient Full Name (text, required)
• Date of Birth (text, required)
• Patient Phone Number (text, required)
• Primary SDOH Concern (dropdown selection, required) — options: Food Insecurity, Housing Instability, Transportation, Utility Needs, Unemployment, Social Isolation, Domestic Violence, Mental Health
• Clinical Context and Reason for Referral (long text, required)
• Patient Consent to Referral? (dropdown selection, required) — options: Yes, Verbal Consent Only, Patient Declined - Refer Anyway per Policy
• Language Needs (dropdown selection, required) — options: English, Spanish, Mandarin, Vietnamese, Arabic, Haitian Creole, Other
• Urgency (dropdown selection, required) — options: Routine, Within 1 Week, Urgent
• Best Time to Contact Patient (text, optional)