Make a Referral

ICAN! makes sure that when you refer a patient or client to one of our community health center partners across the state, they’ll be given the opportunity and the information to decide for themselves if birth control is for them –- regardless of race, gender, sexual orientation, income, or ability.

Connect2Care Form

Many of our health centers now offer telehealth

Connect2Care/Referral Form
Enter your information.
Name
Name
First
Last
*so that we can let you know when the referral has been completed

Enter the patients information.

Patient/Client Name
Patient/Client Name
First
Last

Select Health Centers for Referral.

Select health centers by name. You can review health centers by location in the map below, or search by your referral's location using our health center search.

I have spoken to the patient/client above and they have agreed for me to fill out this Connect2Care form on their behalf. Patient/client and I both understand that this is only for purposes of communication with ICAN!, myself and the selected health center. Text/Emails are sent to make sure the patient/client can get their contraception of choice without barriers.
Consent
Formulario Connect2Care

Ingrese su informacion.

Nombre de la persona que remite:
Nombre de la persona que remite:
Nombre
Apellido
* Para poder informarte cuando se haya completado la remisión

Ingrese la información del paciente.

Nombre del paciente/cliente*
Nombre del paciente/cliente*
Nombre
Apellido

Seleccione centro de salud para referencia.

Seleccione centros de salud por nombre. Para encontrar el centro de salud más cercano a su paciente/cliente, utilice nuestro buscador de centros de salud.

He hablado con el paciente/cliente arriba indicado y ha accedido a que rellene este formulario Connect2Care en su lugar. El paciente/cliente y yo entendemos que esto es sólo a efectos de comunicación con ICAN!, conmigo mismo y con el centro de salud seleccionado. Se envían mensajes de texto/correos electrónicos para garantizar que el paciente/cliente pueda obtener el anticonceptivo de su elección sin barreras.
Consent

Why refer through ICAN?

  • Respect

    ICAN! Quality Hub partners complete unconscious bias, and trauma-informed care training. Shared decision making is at the core of every visit.

  • Low-Cost, High-Quality Care

    All ICAN Quality Hub partners offer the full spectrum of birth control options.

  • Appointment Availability

    At ICAN!, we believe in contraceptive equity: the idea that all people—regardless of race, gender, sexual orientation, income, or ability—should be able to decide whether or not they want to use birth control and what they want to use it for.

About ICAN!

At ICAN!, we believe in contraceptive equity: the idea that all people—regardless of race, gender, sexual orientation, income, or ability—should be able to decide whether or not they want to use birth control and what they want to use it for.

Learn more