ToRCH Community Program

Self-Referral Questionnaire
Our Community Health Team at Phelps Health is here to help Phelps County Medicaid patients find the resources they need. Just complete this questionnaire, and we’ll be in touch. If you qualify, we’ll connect you with the right support.

Please fill out the following so we can get in touch with you:

First Name:*

Last Name:*

Date of birth:*

Phone number:*

Email (if you have one):

Preferred language:

Address*

City/Town*

State*

ZIP/Postal Code*

To qualify for the ToRCH Program, you must meet the following criteria:*

Have MO HealthNet (Medicaid coverage such as Healthy Blue, Home State Health and UnitedHealthcare Community Care Plan) and

Live in Phelps County, Missouri

What kind of help are you needing? (select all that apply)*

Mental health support

Substance use support

Nutrition support or medically tailored meals

Environmental modifications to living area (homes, apartments only) (Ramps, equipment or home modifications)

Chronic condition management (such as diabetes, asthma or high blood pressure)

Something else (please explain):

Do you have a diagnosed medical condition in your health record?*

Yes

I’m not sure

Have you received help from this program before?*

Yes

I’m not sure

Is there anything else you want us to know about your current situation? (optional)

Signed Date:*

Thank you for taking the time to apply.

For questions, please email ToRCHinfo@phelpshealth.org or call (573) 458-8338.

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ToRCH Community Program