Community Risk Reduction Program

Community Risk Reduction Referral Form

Please use this form to refer any community members to the Community Risk Reduction (CRR) workgroup for follow-up.

This form contains protected health information (PHI) and should be treated as confidential.

Person Needing Assistance

First Name: (required) *

Middle Inital

Last Name: (required) *

Address: (required) *

Apartment, suite, etc:

City: (required) *

State: (required) *

ZIP Code: (required) *

Primary Phone Number: (required) *

Secondary Phone Number: (if applicable)required)

Email: (required) *

Date of Birth

Pertinent Medical History (if applicable)

Assistance Needed

Geriatric Care (Bathing, housework, feeding, etc.)Adult Protective Services/Social Services

Is there a current Adult Protective Services (APS) case?

YesNo

Child Protective Services/Social Services

Is there a current Child Protective Services (CPS) case?

YesNo

Injury Prevention (Falls, slips/trips, etcMental Health CareSubstance Abuse/AddictionMedication Assistance (disposal, organizing, administration, lack of medication, etc.)Housing Assistance (homeless or soon-to-be homeless persons, dangerous living conditions, etc.)Fire Safety – Prevention (smoke alarms, electrical hazards, etc.)Fire Safety – Post Incident (Red Cross, returning to normal, etc.)

Was the Red Cross contacted?

YesNo

Currituck Cares/Are You Okay?Meals on WheelsOther:

Comments

Please describe any conditions that you feel warrant the referral.

This form will be submitted to Currituck County Fire & Emergency Medical Services.