FCPC provider referral

Information about referring organization or individual
Do you have permission to refer this family, and do they live in Pierce County? (Please do not proceed if the answer to either is no.)*

YesNo
Your name*
Person referring
Family Connects Nurse Support Referral

Family Connects provides nurse support to families regardless of insurance. They must be pregnant or have an infant under 12 weeks of age to qualify. We will reach out to them after we receive the referral, but nurse visits will not begin until the postpartum period. (If the family qualifies for other programs, such as Maternity Support Services, we may connect them to those programs sooner.) Please only refer a family if they have verbally consented to be contacted by us and if they reside in Pierce County. Any Pierce County family being referred for a Plan of Safe Care will qualify for Family Connects. This form uses HIPAA compliant encryption technology. For questions, email info@familyconnectswa.org
Your role and organization*
ie LICSW, St Joe's
Your phone and/or email in case we have questions*
This is rare
Would you like us to "close the loop" and tell you the outcome of the referral?

YesNoUp to Family Connects
Family's information
Parent/primary caregiver's name*
This may be the birth parent or another individual
Child's name
Okay to write boy, girl, surprise, etc if unknown
Primary caregiver's date of birth*

MonthDayYear
Date
Child's date of birth or EDD*
Family's street address/city
Pierce County address where they will be staying after birth
Family's zip code*
Phone number(s) for family*
Preferred language

EnglishSpanishKoreanRussianTagalogOther
Healthcare information
Birth setting*

Tacoma GeneralSt. Joseph Medical CenterOther
Prenatal care provider
Individual, clinic or group
Pediatric care provider
Individual, clinic or group
This family is (check all that apply):

Already receiving Maternity Support Services (some can receive both)Also being referred for a Plan of Safe Care
Insurance provider
Write "none" if uninsured
This referral is for:

Family ConnectsMaternity Support Services (Apple Health only)Unsure - please confirm eligibility
Circumstances regarding family eligibility for referral: *
Date consent given to submit on-line form*

MonthDayYear
Date
By pressing submit, I acknowledge that this information will be shared with the implemeting agencies of Family Connects Pierce County which may include HopeSparks Family Services, Answers Counseling, and/or Step by Step Family Support.
Should be Empty:

Information about referring organization or individual

Family Connects Nurse Support Referral

Family's information

Healthcare information