HomeMy WebLinkAboutreferral-form-asthma-start-programRevised 04/25/18
Referral to Alameda County Asthma Start Program
(510)383-5181
Staff sending referral: Date:
Agency/Clinic: Phone:
The Asthma Start Program provides free asthma education, asthma risk assessments and linkages to
resources to prevent further asthma episodes. Our goal is to improve the health and quality of life of
children with asthma. Our program can be contacted at (510) 383-5181.
Eligibility
Asthma Start currently provides services to children who meet all the following criteria:
• 0-18 years of age
• Has asthma
• Lives in Alameda County
Child’s Name ______________________, __________________ ____ /_____ /____
Last Name First, Middle Initial Date of Birth
Parent/ ______________________, __________________ _______________________
Guardian Last Name First, Middle Initial Relationship to Child
Street Address_________________________________________ Apt # _______
City _________________________________________ Zip Code __________
Primary language? ___________________Does Child have Medi-Cal ___________ (not mandatory)
Please include Asthma Action Plan, if possible.
Contact Information
Home Phone (______)_______________________
Cell Phone (______)________________________
Work Phone (______)________________________
Please fax completed form to (510) 383- 5183
Or E-Mail asthmastart@acgov.org Or mail completed form to:
ACPHD - Asthma Start Program
7200 Bancroft Avenue, Suite 202
Oakland, CA 94605