Coordinated Intake & Referral Form

REFERRAL FORM

Refer any pregnant woman or parent with a child 3 years or younger residing in Osceola County. Our Connect staff will contact families to provide education, explain resources, and enroll in a home-visiting program to support a healthy pregnancy and infant and child health outcome.
PARTICIPANT INFORMATION
Participant being referred (Please select one)

Pregnant womanInfant/child (under age 3)Mother/Interconception (ICC)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Estimated Due Date

MonthDayYear
Date
Infant Name (if applicable)

First NameLast Name
Infant's Date of Birth (if applicable)

MonthDayYear
Date
Medical insurance?

YesNoUnknown
Medicaid ID (if known)
Address

Physical Address

Street Address Line 2

CityState

Zip
Main Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Best time to call
Email
example@example.com
Authorized methods of contact (check all that apply)

Leave message in my voicemailLeave message with person answering phoneVisit my home if unable to contact meSend letter/correspondence to my home addressText meEmail
Preferred language(s)

EnglishSpanishCreoleOther
Race

WhiteBlack/African American/Multi/BiracialAmerican Indian OR Alaska NativeAsian/Pacific Islander
Ethnicity

HispanicNon-Hispanic
PARTICIPANT CONSENT
I authorize the exchange of my health information between the Healthy Start Program, Healthy Start Providers, Healthy Start Coalitions, Healthy Families Florida, WIC, Florida Department of Health, and my health care providers for the purposes of providing services, compensation for services, improving quality of services or program eligibility.
ParentGuardian Signature
Date

MonthDayYear
Date
OR Verbal Consent Given

Yes
REFERRING AGENCY INFORMATION
Verbal Consent Obtained By:

First NameLast Name
Phone Number
Please enter a valid phone number.
Fax Number
Mailing Address
Referring risk-factors for pregnant woman (select all that apply)

First pregnancyTeen momTobacco usePregnancy interval less than 18 monthsLate or no prenatal careFetal development delayPrevious poor birth outcomeSubstance useOther
Referring risk-factors for infant/child

Low birth weight (less than 5 lbs.)Admitted to NICUSubstance exposureTobacco exposureBirth defectGrowth/development delayLacking family support systemOther
Referral risk-factors for mother or other concerns:

Domestic violencePregnancy lossInfant/child deathHomelessness or instabilityLack of foodLack of clothingLack of shelterLack of transportationLack of healthcareMental health issuesPrenatal supportPost-partum support
Additional comments/other concerns not listed above:
This form contains confidential client information and all HIPAA procedures must be followed.

HealthyStartOsceola.org - Phone: 407-891-9199
Should be Empty:

REFERRAL FORM

PARTICIPANT INFORMATION

PARTICIPANT CONSENT

REFERRING AGENCY INFORMATION