Community Health Promoter Referral Form Refer suburban Cook County residents for local health and social services Community partners, residents and CCDPH staff are invited to complete the below form to refer someone to a CCDPH community health promoter for targeted community outreach or referrals to resources, including: employment, food, healthcare, housing, transportation, and other services. Download the Resources & Services palmcard (PDF; English/Spanish)Client's city and zip code(Required)Must live in suburban Cook County City Zip Code (five digit) Please note: To proceed, please complete the 5-digit zip code field with a suburban Cook County zip code (excluding those in Evanston, Oak Park, Skokie and Stickney Township, which are outside CCDPH's jurisdiction and have their own state-certified health departments). If you live in one of these suburbs or outside suburban Cook County, please visit your local health department for more information about services in your area.Referral InformationPlease tell us who is making the referral CCDPH Staff Community-Based Organization Elevate Event Referral Self/Resident Other OtherStaff Name(Required)From which unit or program are you referring the client?(Required)Administration & OperationsBehavioral HealthBHC 2030Chronic Disease Prevention & ControlCommunicable Disease ControlCommunicationsCommunity Engagement & Health EducationEnvironmental HealthEmergency Preparedness & ResponseEpidemiologyHealthy Beginnings ProgramHealthy Work InitiativeImmunization ProgramLead Poisoning Prevention & Health HomesPublic Health NursingPublic Health PolicyTuberculosis ControlOtherOtherConsent and Privacy(Required)The client has indicated or verbally consented to the Community Health Promoter Program collecting and using personal information for assistance purposes Yes No Client urgency status Urgent: The client has an urgent need and a CHP will reach out within 24 business hours Non-urgent: The client need is not urgent and a CHP will reach out in 48 business hours **referrals received after hours or during the weekend will be processed the next business day Urgent Non-urgent Client InformationPlease provide full name, contact info, and client preferences.Client's full name First Last Client's Date of BirthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Client's city and ZIP code(Required)Must live in CCDPH’s jurisdiction of suburban Cook County (excluding Evanston, Oak Park, Skokie and Stickney Township, which have their own state-certified health departments). City ZIP / Postal Code Client's phone number(Required)If not a direct phone number, please indicate who the number belongs to and the relationship to the clientBest time to contact clientMorningAfternoonEveningAnytimeOtherOtherClient's email addressPlease write the client email address, if available Client's preferred language(Required) English Spanish Arabic Polish Other OtherPrimary reason for request(Required) Childcare & Parenting (e.g., after-school programs, childcare centers, child support services, family doctors, parenting classes, pediatricians) Clothing & Household (e.g., clothing, furniture, household goods assistance programs) Employment & Income (e.g., disability, links to unemployment insurance, mortgage, rental, Social Security benefits, utility assistance) Food (e.g., Meals-on-Wheels, P-EBT, school lunch programs, SNAP, WIC) Government & Legal (e.g., benefits enrollment assistance, housing rights organizations, immigration services, legal aid clinics, social services offices) Healthcare (e.g., clinics, Federally Qualified Health Centers, medical insurance, primary care providers) Housing & Shelter (e.g., emergency shelters, housing assistance programs, rental assistance services, transitional housing, and resources for people experiencing homelessness or housing insecurity) Mental Health & Substance Use (e.g., counseling, harm reduction services, mental health treatment and support, recovery and supportive housing, substance use treatment and support) Transportation (e.g., transportation services to qualifying locations like food pantries, government agencies, and healthcare) Other OtherTransportation DetailsEmail (Required for Ride Confirmation)(Required) Number of riders(Required)Destination type (hospital, food pantry, clinic, etc.)(Required)Address of pick up location(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Address of drop-off location(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Appointment Date(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Appointment Time(Required) Hours : Minutes AM PM AM/PM Round trip ride needed?(Required) Yes No Special accommodations needed?(Required)Check all that apply. None Car Seat/Booster Seat (needed) Car Seat/Booster Seat (rider providing) Wheelchair (needed) Wheelchair (rider providing) Non-Rideshare (rider has or suspected of having an infectious disease) Rider Assistance (door to door) Additional comments or notes Δ Updated September 14, 2026, 12:02 PM
