The Center for New North Carolinians | Research | Our Research Projects | IHAP Referral Form

IHAP Referral Form

IHAP serves immigrants and refugees who live in Greensboro only. Languages available are Spanish, French, Swahili, Kinyarwanda, Kirundi, Vietnamese, Jarai, Rhade. To make a referral, please use the below form. Alternatively, you can download the form here and submit via email to [email protected].

"*" indicates required fields

Referral Source Information

Date of Referral*
Name*

Client Information

Full Name*
Date of Birth*
Home Address*
Country of Origin*
Arrival Date (if client is a refugee)
Client Speaks English*
Client is Aware of Referral*
Family Members Need Assistance
If yes, please complete a separate form for each, noting relationship

Health Access Information

Insurance Status*
Primary Care Provider

Reason For Referral

Has your agency provided any initial interventions?*
Will your agency be providing any ongoing assistance?*
This field is for validation purposes and should be left unchanged.
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