T

Healthy Start - T.E.A.M. Dad Agency Referral Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Primary Phone Number
Other Phone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AptUnit
State
Zip
Languages Spoken:

EnglishSpanishHaitian CreoleOther
Marital status:

MarriedSingleDivorcedSeparatedWidower
Does participant have any children?

No, this is/will be the first childYes, has other children
Name of Parent/Guardian (if under the age of 18)
Relationship to Participant
Mom and Infant/Child Information
Child/Infant Name (First and Last)
Mom Name (First and Last)
Mom DOB
InfantChild DOB
Referral Reason:

Mother is in Healthy StartMother is in other Home Visiting ProgramMother is pregnant and NOT receiving any Home Visiting ServicesInfant/Child is in Healthy StartInfant child is in other Home Visiting ProgramInfant/Child is NOT receiving any Home Visiting Services
Person Making Referral
Date Referred

MonthDayYear
Date
Agency/Program
Phone Number
Email Address
example@example.com
Fax Number
Best way to contact Dad
Release of Information Consent
I, (type name of dad or minor dad's legal guardian)
give my permission for
(type name of person making referral)
to share any and all pertinent information regarding me or my child,
(type dad's name)
with the T.E.A.M Dad Program listed above and the Referring Agency to learn more about the program and determine eligibility. I have read this Consent before signing and fully understand the contents, meaning and impact. I understand that I am free to address any specific questions and have done so prior to signing this Consent. I understand that I have the right to revoke my consent by informing representatives from the T.E.A.M. Dad program.
Signature

Clear
Date

MonthDayYear
Date
Select whose signature is being provided

ParticipantParent/Legal Guardian
( Participant orParent/Legal Guardian)

This form will expire 60 days from date of signature.
Should be Empty: