Health Connect America Online Referrals

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Service Details
Referring Agency Details
You have informed the person / family
You have not informed the person / family
This person is on medications
This person is not on medications
Client Information Details
Client's gender is Male
Client's gender is Female
Client's gender is Nonbinary
Client's gender is Other
Client is white, but not Hispanic
Client is Haspanic or Latino
Client is not Hispanic or Latino
Client is a Tobacco User
Client is a Tobacco Non-User
Client's Tobacco Use is unknown
Smoking Status is Everday
Smoking Status is Some Days
Smoking Status is Former Smoker
Smoking Status is Never Smoked
Other Client Details
If Underage or Adjudicated Incompetent as Adults
Additional Questions
Insurance Information
There is secondary insurance
There is not secondary insurance
A letter of service denial is available
A letter of service denial is not available