Language
English (US)
Spanish (Latin America)
REFERRAL FORM
Lincoln Trail District Health Department HANDS Program Serving: Hardin, Larue, Marion, Meade, Nelson, and Washington counties. Phone: Call your local health center and select option #3. Fax: 270-681-3606. Email: LTDHDHANDS@LTDHD.ORG
Parent Name (Mom/Dad/Custodian)
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Can we text this phone number?
Yes
No
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Due Date/Birth Date
Interpreter needed?
Yes
No
If yes, what language?
Is infant less than 90 days old?
Yes
No
Referred By(Name)
Referred By(Agency)
Signature
Submit
***FOR OFFICE USE ONLY***
Date Form Received in HANDS Office
Person Receiving Form
Date(s) of Contact Attempts
Notes:
Should be Empty: