Self-Referral Form

Evidence-Based Program Self-Referral Form

Requirement: Lewis County Resident AND 18 years of age or older.

Please fill out the following form if you are interested in one of the following classes:

*If the form is not working correctly, please contact (315) 376-5453 and ask for a Public Health Specialist.

*Today's Date

*Name (First, Last)

*DOB (18+ only)

*Phone Number

Secondary Number

*Address

*City

*State/Province

*Zip Code

*E-mail

*Which course are you interested in?

*For the Lifestyle Change Program (Diabetes Prevention Program), please choose one of the options below:

*For the Diabetes Self-Management Program, has a medical professional told you that you have diabetes?

*For the Chronic Disease Self-Management Program, has a medical professional told you that you have a chronic illness?

*For Tai Chi for Arthritis, (60 years of age or older AND one or more of the following)

*For Walk with Ease (60 years of age or older AND must be able to be on your feet for at least 10 minutes without increased pain))

*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?

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