• Community Health Worker Referral Form

    Please complete the following information.
  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Do you live in Wake County?*
  • What language are you most comfortable speaking?*
  • Race
  • Ethnicity
  • Marital Status
  • Do you need assistance with one of the following services? (Select your top 3 priorities.)*

  • The system we use to track services is called NCCare360. I must get your consent to be entered into that system. (If they consent to being entered in NCCare360 read them the Unite Us verbal consent script and proceed. If they decline but want services, honor their request. Emphasize that their ability to receive services will not be affected by their decision to consent to NCCare360 Unite Us verbal script for consent to participate in the Unite Us Network).


    Read the following attestation:
    By consenting, you agree to share information with a Network of health and social service partners powered by Unite Us software. Your personal information may be shared securely on the Network in accordance with privacy laws to connect you with services. This consent covers all information shared by you or by anyone that has the right to share information on your behalf. You can always limit the information you provide on the Network by requesting
    to have it removed. To understand how your information may be used and kept safe on the Network, please see uniteus.com/privacy.

    If you no longer want your information shared on the Network, you can email consent@uniteus.com or ask any Network partner. It will take three business days to stop sharing your information.

  • Do you provide your consent?*
  • Do you understand and agree with what I have just read?*
  • Did I give you a chance to ask any questions that you had?*

  • I attest that I read the consent document to {nameOf}, gave them the opportunity to ask questions and answered the questions asked. I affirm that {nameOf} then provided consent for his/her information to be shared via the Unite US platform.

  • Received consent:*
  • Method of consent*
  • Reload
  • Should be Empty: