Northeast Florida Coordinated Intake & Referral Form
Client & Family Information
Mother/Caregiver's Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Infant/Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
Email
example@example.com
Best time to contact:
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Medical insurance covered by:
Doctor's Name
# of weeks pregnant
Estimated due date
-
Month
-
Day
Year
Date
Race
Please Select
Black/African American
Multi/Biracial
White
Asian/Pacific Islander
American Indian or Alaska Native
Language of prefence:
Risk Factors (Select all that apply)
Pregnant Woman
First pregnancy
Under 18 years old
Substance exposure
Tobacco use (mother)
Tobacco use (other household member)
Pregnancy interval less than 18 months
2nd trimester entry or no prenatal care
Chronic health problem/illness
Fetal developmental delay
Had a baby not born alive
Had a baby born more than three weeks before due date
Had a baby weighing less than 5 lbs. 8 oz.
Additional information:
Infant Gender
Male
Female
Infant:
Low birth weight (less than 4 lbs. 7 oz.)
Admitted to NICU
Substance exposure
Tobacco exposure
Birth defect
Growth/developmental delay
Special needs
Father is not involved
Additional information:
Mother/ICC:
Child not in mother's guardianship
Child placed for adoption
Pregnancy loss
Infant/child death
Mental health (history or current): i.e. depression, high stress, anxiety, hopelessness
Additional information:
Other concerns or needs:
Domestic violence (past or present)
Open dependency case
Incarcerated
Plan of safe care
Children under age of five in the home
Death in immediate family
Homeless or unstable
Lack of other basic needs (food)
Lack of other basic needs (clothing)
Lack of other basic needs (transportation)
Lack of other basic needs (healthcare)
Prescription medication needs
Environmental/occupational exposure
Lack of support
Military family
Prenatal/postpartum doula support
Additional information:
Client Consent
I accept the invitation to participate in an Initial Intake and if eligible, one of the Community Connect Home Visiting Programs. I consent that this information be shared with the Northeast Florida Healthy Start Coalition, my Medicaid/Insurance provider and its programs: Healthy Start, Healthy Families, The Magnolia Project, CAPTA/Seeking Safety, Early Head Start and Nurse Family Partnership. I understand that this information will be held strictly confidential.
Signature
*
How did you hear about CONNECT?
*
Hey Mama (brochure, flyer, billboard, radio, TV, digital)
Friend or family member
NEFHSC staff member or event
Social Media
Health Care Provider
Community program
Referral Information
Referrer's Name
First Name
Last Name
Referrer's Title
Referrer's Phone Number
Please enter a valid phone number.
Referrer's Agency
Referrer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referrer's Signature
Submit
Should be Empty: