RFCC Women's Services Registration Form

Organization RFCC Logo

RFCC Logo

WOMEN’S SERVICES REGISTRATION FORM

PLEASE PRINT TODAY’S DATE: ___________________

Name:	Birth Date:					Phone (home):				Phone (work):
Mailing Address: City: State: Zip:										Email Address:
What is the best way to reach you?  Telephone  Mail  Email					Reason for Contact:
Marital Status:  Married  Widowed  Separated  Never married  Divorced  Live with partner					Hispanic?  Yes  No  White  American Indian/Alaska Native  Black/African American  Multiracial  Asian  Unknown/Unreported  Pacific Is./Hawaiian
Emergency and Follow-up Contact Information:
Name:				Phone (home):					Relationship
Address: City: State: Zip:
People living in your household: Name Relationship to you Age ____________________________ ________________________ ___________ ____________________________ ________________________ ___________ ____________________________ ________________________ ___________ ____________________________ ________________________ ___________ ____________________________ ________________________ ___________
Do you need transportation to medical or other health-related appointments?  Yes  No			Do you currently have health insurance?  No  Yes (If yes, check one)  Private  Medicare  Medicaid  Other:_________________________
Do you have difficulty paying for healthcare?  Yes  No
Highest Level of Education:  Less than High School Graduate  High School Graduate  GED  Some College  College Degree or higher			Do you have a disability?  Yes  No If yes, what is your disability? ____________________________				Are you currently pregnant?  Yes  No
Are you employed? Full-time Part-time Homemaker Self-employed Unemployed, laid off Unemployed, looking for work					What is your approximate family income per year? (before taxes)
					Under $ 20,000 $20,000 - $25,000 $25,001 – $30,000					$30,001 - $35,000 $35,001 - $40,000 $40,001 or more
Would you be interested in learning about the following services:
Substance Abuse Nutrition Family Abuse/Safety programs Disease Management Medical Services: Neurologist/neurosurgeon Treatment for skin - Dermatologist Urologist Counseling - Behavioral Health Dentist Other:______________________		Healthy Lifestyles Tobacco Cessation Transportation Other:______________________ Cardiologist Cancer treatment -Oncologist Internal Medicine Pharmacy Eye doctor - Ophthalmologist						Parenting Classes Stress Management Prenatal health services OB/GYN Orthopedist Family Medicine Radiologist Pediatrician for my kids

Is there anything else we can help you with?

For Office Use Only

Name of County Where Patient Resides:________________________________________

County Designation:  Urban  Suburban  Rural  Frontier

RFCC Program Site: ________________________________________________

Registration Form Completed By:  Patient  Provider/Staff

Registration information submitted via:  Paper Form  Telephone  Website

Navigant Consulting Inc. Appendix E

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