HomeMy WebLinkAboutdiabetes-referral-form-20260630-202202018
REFERRAL TO ALAMEDA COUNTY
DIABETES SELF-MANAGEMENT EDUCATION AND SUPPORT SERVICES
Referring Staff: Date:
Referring Agency/Clinic: Phone: Fax
Eligibility
18 years of age or older
Diagnosed with type 2 or pre-diabetes
Lives in Alameda County
Through an 8 week American Diabetes Association Recognized program these topics will be covered:
• Diabetes Overview
• Healthy Eating
• Taking Medications
• Reducing Risk
• Healthy Coping
• Being Active
• Monitoring
• Problem Solving
Patient Name: Date of Birth:
Street Address: ___________________________________ Apt #:_________________
City: ____________________________________________ Zip Code: __________________
Phone Number: Female Male
Diagnosis: Pre-Diabetes Type 2 Diabetes
Language: English Farsi Hindi
Punjabi Spanish Urdu Other: ________________________________
Please fax completed form to the
Alameda County Diabetes Program at (510) 383- 5183.
For Office Use
1st Call (Date/Initial):________/_____ 2nd Call (Date/Initial):________/_____ 3rd Call (Date/Initial):________/_____
□ No answer, letter sent: □ No answer □ No answer
□ Left Message, letter sent □ Left Message □ Left Message
□ Phone D/C; letter sent □ Phone D/C □ Phone D/C
□ Declined Services □ Declined Services □ Declined Services
□ Will attend class: □ Will attend class: □ Will attend class:
□ Other: □ Other: □ Other:
□ Outcome Fax Sent (Date/Initial)