Bernalillo County Home Visiting Common Referral Form

Contact Us
About Us
Library
Register
Login

Resource
Directory
Social
Initiatives
County
Pages
- Contact Us
- About Us
- Library
- Register
- Login

Contact Us

Use this form to send us comments, questions or suggestions, or to request information for subscriptions or sponsors. SHARE is built by and for New Mexicans, and we rely on you to provide input and content for these pages. Share what matters to you.

Name

Are you over 65?

Phone (optional)

Race/Ethnicity

Zipcode inquiring about services in

Inquiry

I have read and understand the disclaimer below and consent to being contacted by the SHARENM Navigator based on the information and inquiry I have submitted

Show disclaimer

By submitting this inquiry form, you acknowledge and agree that: (i) The information you provide will be shared only with the SHARENM Navigator, not with any external service provider; (ii) the SHARENM Navigator will contact you by phone or email to assist with your request and help connect you to appropriate services, programs, or resources; and (iii) Submitting this form does not guarantee that you are eligible for services or that a connection to a provider will be made.

Please do not include sensitive personal information. SHARENM is not a HIPAA-covered entity and cannot receive or store Protected Health Information (PHI). For more information about how your data is handled, please read our Privacy Policy

If you need help completing this form or prefer assistance in another language? Please call 505-289-0558

Si necesita ayuda con esta información por favor llame al numero 505-289-0558

If you need assistance due to a disability or require the form in an alternative format, please contact us and we’ll do our best to accommodate your needs.

Tel: 505-289-0558 or email martha@nmhealthcouncils.org

Tel: 505-552-2147 or email melissa@nmhealthcouncils.org

Share information resources to support change

Download

Bernalillo County Home Visiting Common Referral Form

Author: Bernalillo County Home Visiting Work Group
Year:
Format: Written Document

A common referral form for use by the programs affiliated with the Bernalillo County Home Visiting Work Group. For more information, contact Cathy Sanchez, csanchezpreissler@salud.unm.edu.