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Community Outreach Form (for CHW use only)

Name(Required)

First Last

Date of Birth(Required)

Month

Day

Year

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Referral from(Required)

La Familia Sana

Cloverdale Apartments

Senior Center

King’s Valley

Other

Is Client a patient at Alexander Valley Healthcare?(Required)

Yes

No

Do you have Insurance?(Required)

Yes

No

What insurance?(Required)

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Referral to

Referral for(Required)

Check all that apply

Primary Medical Care

Dental Services

Behavioral Health

Substance Abuse

Medi-Cal

Emergency Medi-Cal

Covered California

Cal Fresh

Family Pact Program

Cancer Detection Program

Sliding Scale Program

Other

Reason – Primary Medical Care(Required)

Reason – Dental Services(Required)

Reason – Behavioral Health(Required)

Reason – Substance Abuse(Required)

Reason – Medi-Cal(Required)

Reason – Emergency Medi-Cal(Required)

Reason – Covered California(Required)

Reason – Cal Fresh(Required)

Reason – Family Pact Program(Required)

Reason – Cancer Detection Program(Required)

Reason – Other(Required)

Reason – Sliding Scale Program(Required)

Ethnicity(Required)

Latino/Latinx

Indigenous Mexican and Central Americans (Mam, Mixteco, Triqui, Chatino, etc.)

Native American

People who live in insecure housing

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Contact

Medical Offices:

6 Tarman Dr.
Cloverdale, CA 95425

Dental Offices:

100 W 3rd St.
Cloverdale, CA 95425

Alexander Valley Healthcare is an FTCA deemed facility. AVH is a Health Center Program grantee under 42 U.S.C. 254b and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

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