Health Service Request Forms

Are you interested in BCHD coming to your event? Please review the list of available programs and partners and their respective services listed below. Availability is based on staffing, date and target population. Form only acts as a notification to the appropriate programs to request their participation. Requests for health services must be submitted at least 15 days in advance but some programs need additional notice. Program participation is contingent upon staff availability and scheduling. Please fill out the online Health Service Request Form or download and complete the pdf BCHD Health Service Request Form. Email the completed electronic PDF or any questions to Victoria.Minka@BaltimoreCity.gov

NOTE: Pictures of completed forms will not be accepted. 

Available Programs and Partners 

Div. Youth Wellness & Community Health
Maternal & Child Health (MCH)

• MCH: Baltimore Infants & Toddlers – Health education and program materials; Giveaways  
• MCH: Adolescent & Reproductive Health – Health education and program materials; Condoms

Chronic Disease Prevention (CDP)

• CDP: Tobacco Education & Cessation – Tobacco and smoking health education and program materials; Cessation classes; Workshops 
• CDP: Baltimarket Virtual Supermarket - Partners with a Supermarket (Giant Food) - Support for persons in Healthy Food Priority Areas (HFPA); Access to healthier food options via education on online grocery shopping

Health Homes (HH)

• HH: Asthma – Health education and program materials; Home visiting information 
• HH: Lead – Health education and program materials; Risk assessment information, Free Lead inspections; Cleaning kits and resources

Office of Youth & Trauma Services (YTS)

• YTS: Youth & Trauma Services – Health education and program materials

Div. Population Health & Disease PreventionLocal Health Improvement Coalition (LHIC)

• LHIC: CharmCare – Health education and program materials; Social needs screenings; Referrals to city resources; Promotional items
• LHIC: Local Health Improvement Coalition - Health education and program materials

Public Health Preparedness and Response (PHPR)

• PHPR: Preparedness & Response – Health education and program materials; Planning for Emergencies information; Presentations

Overdose Prevention (OP)

• OP: Kids Off Drugs - Youth Overdose Prevention Education (for schools and universities ONLY) – Health education and program materials; Culturally relevant education through art, music, and literature

Community Risk Reduction Services (CRRS)

• CRRS: Needle Exchange Van – Health education and program materials; Syringe service exchange
• CRRS: Harm Reduction Services – Health education and program materials; Overdose education; Narcan distribution
• CRRS: Naloxone (Narcan) Training - Health education and program materials; Naloxone Trainings

HIV/STI Prevention (HP)

• HP: HIV/STI Prevention Education - Health education and program materials; Condoms
• HP: HIV/STI Testing - Health education and program materials; Free and confidential HIV and STI testing and counseling (offered to all persons 13 years of age and up); Condoms

Oral Health (OH)

• OH: Oral Health (need 3 week notice) – Health education and program materials; Dental supplies

Div. Aging & Community Support
Advocacy Services (AS)

• Maryland Access Point – Health education and program materials
• State Health Insurance Program (SHIP/SMP) – Health education and program materials

Home and Community-Based Services (COS)

• Family Caregivers – Health education and program materials

Client Services (CLS)

• Guardianship – Health education and program materials

Other Direct Community Partners

• Water4All Assistance – Health education and program materials; Water Access assistance
• Office of Child & Family Success – Health education and program materials
• Civic Works – Health education and program materials; Youth jobs; Water 4 All Application assistance; Home Energy Program information; Elderly Services information
• Home Energy Program – Health education and program materials; Energy Program assistance
• Maryland Insurance Administration (need one month notice) – Insurance education and program materials; Presentations; Trainings
• MedStar Family Choice – Health education and program materials; Fitness band demonstrations; Giveaways
• Green & Healthy Homes Initiative - Lead poisoning, asthma, and injury prevention health education and program materials; comprehensive direct housing services
• DHCD Programs - Health education and program materials
• HCAM Diabetes - Health education and program materials
• MedStar Colon/Lung Cancer Screening
• Baltimore City Cancer Program
• MIMA Immigrant Affairs