Get Community Health Worker Application Form

Filling out the Community Health Worker Application Form online can be a straightforward process with the right guidance. This step-by-step guide will walk you through each section of the form, ensuring that you provide all necessary information accurately.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your browser.
2. Begin with entering the date of referral at the top of the form. This is the date on which the referral is initiated.
3. In the section labeled ‘Target Client Name’, input the last name, first name, and middle initial of the client being referred.
4. Indicate the marital status of the client by selecting one of the boxes. Options include: Single, Partnered, Married, Separated, Divorced, or Widowed.
5. Provide the client's date of birth in the specified format. This information is essential for identifying the correct individual.
6. Fill in the name of the person making the referral in the designated section. This is typically the individual completing the form.
7. Enter the agency, provider, or organization name that the referrer represents.
8. Complete the address fields including street address, city, state, and zip code for the agency or provider.
9. Document the name of the Public Health Services (PHS) staff member who is accepting the referral in the provided space.
10. Include the contact phone number and date for follow-up communications regarding the referral.
11. Finally, review all the entered information for accuracy before submitting. You can save changes, download, print, or share the form as needed.

Begin your online application today to connect with essential health services.