Self Referral Form

Please Note: Filling out this form means you’re asking to be connected to a Community Health Worker from Samuel U. Rodgers Health Center. They may be able to connect you with resources to meet social or medical needs that you or someone in your care may have. Once completed, this form is sent to Sam Rodgers, and someone will contact you within three business days. The information you enter is completely confidential and there is no cost for this service. Please use this form only to request services for yourself or a child (under 18 years old) or adult for whom you have legal guardianship. Consent submitted through this form should be signed by the person who would be receiving services or by their parent or legal guardian only.

Partner agencies, please use this form to refer patients in need of resources.