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SCORE Program Client Referral Form

Community Health Worker (CHW) Program - Sickle Cell Disease (SCD) Support

Use this form to refer an individual for services provided by the SCORE program. This form may be completed by the client, a caregiver, or a referring provider to connect individuals with tailored support for managing sickle cell disease (SCD).

Referral Type

* must provide value

I am a person living with Sickle Cell Disease referring myself

I am referring someone else

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Please describe your relationship to the client you are referring:

* must provide value

Parent/Guardian

Other Family Member

Healthcare Provider

Social Worker or Case Manager

Other

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Please describe your relationship to the client you are referring:

* must provide value

Please provide a phone number or email address where we can reach you in case we need to confirm referral information:

* must provide value

Referring Provider Name:

Healthcare providers, social workers, case managers, etc.

* must provide value

Organization/Practice Name:

* must provide value

Provider's Phone Number:

* must provide value

Provider's Email Address:

* must provide value

Full Name:

* must provide value

Date of Birth:

* must provide value

M-D-Y

Gender:

* must provide value

Male

Female

Non-binary/Other

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Race/Ethnicity (Check all that apply):

* must provide value

Asian

Black or African American

American Indian or Alaska Native

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Hispanic or Latino

Prefer not to respond

Other

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Primary Language Spoken:

* must provide value

Client Phone Number

* must provide value

By checking this box, I consent to receive conversational SMS from The SCORE program, facilitated by HealthHIV. Reply STOP to opt-out; Reply HELP for support; Message & data rates may apply; Messaging frequency may vary. Visit https://sicklecellchw.org/privacy-policy/ to see our privacy policy and SMS Terms and Conditions. No mobile opt-in or text message consent will be shared with third parties or affiliates.

Client Email Address

* must provide value

Client Home Address

County

* must provide value

Street Address:

* must provide value

City:

* must provide value

State:

* must provide value

Maryland

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Zip Code:

* must provide value

Does the client have a confirmed SCD diagnosis?

* must provide value

Yes

Unsure

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Does the client currently receive care from an SCD specialist?

* must provide value

Yes

Unsure

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If known, please provide the specialist's name:

Are there barriers the client faces in managing their SCD? (Check all that apply):

* must provide value

Access to medications

Attending medical appointments

Understanding the treatment plan

Transportation to care facilities

Financial difficulties

Other

Please describe any other significant barrier(s) preventing the client from managing their SCD:

* must provide value

What services does the client need? (Check all that apply):

* must provide value

Medication adherence support

Assistance with appointment scheduling

Education on managing sickle cell disease

Connection to community resources

Pain management strategies

Transportation assistance

Financial resource navigation

Other

Please describe the client's needs:

* must provide value

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Is the client aware you are referring them to the SCORE program?

* must provide value

Yes

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Please inform the client that you have referred them to this program.

Additional Comments or Relevant Information:

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Referral received by:

Date received:

M-D-Y

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Assigned CHW

Client ID:

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