Form Center • CHW Referral Form

Thank You for Your Referral

Community Engagement Team
ATTN: Community Health Workers
14949 62nd Street North
Stillwater, MN 55082
Call or Text: 651-286-9120
Email: AskCHW@washingtoncountymn.gov
Complete this form to refer yourself or someone else for help from the Community Health Workers. Please do not provide any protected health information on this form.
Requested Assistance
Check all that apply.
1. Emergency assistance
2. Healthcare programs
3. SNAP
4. WIC
5. Homeless resources
6. Employment assistance
1. Register for Parks program or event
2. Refugee or immigrant services
3. Register to vote
4. School attendance
5. Learning opportunities
6. Volunteer opportunities
Continue

- I understand that submitting this form is voluntary.
- If I am submitting this referral for someone else, I acknowledge having received consent from any person(s) listed on this form.
- By submitting this form, you allow a Community Health Worker to contact you.
Type your name to sign electronically*

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