Diabetes Prevention Program Interest Form

Thank you for your interest in Crook County’s Diabetes Prevention Program. This free, year-long program is designed for adults who have prediabetes or other risk factors for type 2 diabetes. Participants work with a lifestyle coach in a group setting to make healthy changes to prevent type 2 diabetes. By filling out the form below, your information will be sent to the Health Department Staff. If you qualify for the program, a staff member will reach out to you.

Type Of Referral: *
Date of Birth:
Have you been diagnosed with type 1 or type 2 diabetes? *
Have you been diagnosed with prediabetes? *
Do you have a family history of type 2 diabetes? *
Have you been diagnosed with High Blood pressure? *
Date:
I understand that an employee from Crook County Health Department Diabetes Prevention Program will contact me to find out if I qualify. *
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