Self-Referral Form

*Today's Date

*Name (First, Last)

*Phone Number

Secondary Number

*Address

*City

*State/Province

*Zip Code

*E-mail

*Which course are you interested in? Diabetes Prevention Program Diabetes Self Management Program Chronic Disease Self Management Program

*For the Lifestyle Change Program (Diabetes Prevention Program), please choose one of the options below: History of gestational diabetes Fasting plasma glucose (100-125 mg/dL) Hemoglobin A1C (5.7%-6.4%) Pre-diabetes Risk Assessment Score of 5 or Higher Not applicable

*For the Diabetes Self-Management Program, has a medical professional told you that you have diabetes? Yes No Not applicable

*For the Chronic Disease Self-Management Program, has a medical professional told you that you have a chronic illness? Yes No Not applicable

*Who is your Primary Care Provider?

*What days of the week would work best for you to attend a class?

*What times of the day would work best for you to attend a class?

Do you have any family members/friends that are also interested?

*How did you hear about the program?

Additional comments?