PROGRAM REFERRAL FORM

Program Referral Form
Referral Type*

Community Partner Referral (Community Partner submitting referral on behalf of a consenting family)Self Referral (for parent or guardian, NOT for Community Partner use)
Community Partner Agency*
Community Partner Type*
Other Community Partner Type
Enter Agency or Agency Type
Community Partner Information
Consent Statement*

The referred family has consented to share the information on this form with Connect and collaborating agencies. This referred family understands that this information will be confidential.
Verbal Consent Given By*
First and Last Name of Client, Parent, or Guardian
Verbal Consent Obtained By*
Referring person who obtained client consent
Date*

MonthDayYear
Phone Number of Referring Community Partner*
Format: (000) 000-0000.
Fax Number of Community Partner
Format: (000) 000-0000.
Email Address of Community Partner*
Supervisor Name*
Supervisor Email Address
Date

MonthDayYear
Client Information
Client (select one)*

Pregnant WomanInfant (Under age 3)Interconceptional Woman (Woman who had a loss or removal of infant within last 18 months.)Expectant FatherFather with Child (Under age 5)
Interconceptional Woman

Child not in mother's guardianshipPregnancy lossInfant deathChild placed for adoption
Only select YES for Continuation of Services (IA or External II) - Healthy Start, NFP, NHVP*

YesNo
Estimated Due Date

MonthDayYear
Date
Estimated Due Date

MonthDayYear
Date
Date of Loss

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Date of Death

MonthDayYear
Date
Caregiver Information
Caregiver Type

ParentGuardian
Relationship to Child
Medical Insurance?

YesNo
Medicaid ID
First Name*
Last Name*
Gender
Date of Birth*

MonthDayYear
Date
Physical Address*
Apt
City*
State*
ZIP Code*
County*
Main Phone*
Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
Email
example@example.com
Infant Information
Infant First Name
Infant Last Name
Gender
Infant DOB

MonthDayYear
Date
Allowed Correspondence
Phone
Leave VoicemailText Message
Teen Privacy
YES
Preferred Language(s)

EnglishSpanishCreoleOther
If Other, Preferred Language(s)
Risk Factors (Select All That Apply)
Pregnant Woman

First pregnancyPregnant teenSubstance exposure - HistorySubstance exposure - CurrentSubstance exposure - Other member of householdTobacco use - HistoryTobacco use - CurrentTobacco use - Other member of householdPregnancy interval less than 18 monthsPrior poor birth outcome - Had a baby not born alivePrior poor birth outcome - Had a baby born more than 3 weeks before due datePrior poor birth outcome - Had a baby weighing less than 5lbs 8oz
Substance Exposure Type
Infant

Low Birth Weight (less than 4lbs 7oz)Admitted to NICUFather is not involvedTobacco exposureSubstance exposureGrowth or developmental delayChronic illness or health problem
Substance Exposure Type
Chronic Illness or Health Problem Type
Additional Concerns

Domestic violence (past or present)Open dependency caseMental health (or history of): depression/stress/anxiety/hopelessnessOther children under the age of 5 in the homeDeath in immediate family or child deathHomeless or unstable housingLack of supportIncarcerated parentMilitary familyLow family or student academic achievementTeen parent
Home Visiting Services That Interest You (Select All That Apply)

Visits at home to support moms and dadsGuidance for pregnancy and giving birthHow to take care of baby and keep them safeHelp with breastfeedingLearn about healthy food optionsHelp with planning your familyLearn how children grown and changeLearn positive parenting skillsLearn how to keep your baby safe in the carHelp your child prepare for schoolHelp from a counselorHelp keeping your baby safe from exposure to smoke, tobacco, alcohol, or drugsHelp after pregnancy or infant loss
Additional Comments/Intake Information
For additional comments, please use the file upload feature.
File Upload

Upload any additional information or relevant files for this case.
Cancelof
Self Referral Consent
I consent to share my information with the Connect Program
Enter your full name to complete the self referral consent:
Risk Factors Addressed

Use the following fields to indicate any risk factors addressed with the client.
Risk Factor
Action
Risk Factor
Action
Education
All education items must be provided to clients. Explain in the notes section below if any items have not been provided.

The referral will not be processed without this information.
Medicaid education was providedFamily Planning education was providedWIC information was provided211/Community Resources information was providedPrenatal/Postpartum Care education was providedSafe sleep education was provided
Notes
Correspondence Allowed

MailEmailPhoneText MessageLeave VoicemailLeave MessageHome Visit
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Program Referral Form

Community Partner Information

Client Information

Caregiver Information

Infant Information

Risk Factors (Select All That Apply)

Self Referral Consent

Risk Factors Addressed

Education