CIDS Referral Form
CIDS has several voluntary programs (Nurse Family Partnership, Healthy Families, School Readiness Program, First 1,000 Days and the Screening Team) designed to provide expectant and new parents/families in Chemung County with referrals, resources, information and support. The programs are free of charge. Please complete this form and we will contact you to provide more information about our programs and services.
Consenting Parent or Caregiver
Please fill in this section for all referrals.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Postal / Zip Code
Postal / Zip Code
Parent / Caregiver Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Race / Ethnicity
Preferred Pronoun
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
Primary Insurance:
*
Medicaid
Private Insurance
No Insurance
Other
Unknown
Marital Status
*
Single
Married
Partnered
Divorced
Widowed
Other
Unknown
Does the family receive and/or is eligible for:
*
WIC
SNAP
TANF
SSI/SSD
Other
N/A
Does the consenting parent / caregiver have a primary care doctor?
*
Yes
No
Unknown
Has the family been enrolled in a CIDS program before?
No
Yes, but not sure of the program
Yes, Nurse Family Partnership (NFP)
Yes, Healthy Families (HF)
Yes, School Readiness Program (SRP)
Yes, First 1,000 Days (F1KD)
Yes, Screening Team
Unknown
If the family has been involved in a CIDS program before and can remember their Home Visitor's name, please add it below.
Home Visitor's Name
Secondary Parent or Caregiver
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Postal / Zip Code
Postal / Zip Code
Phone Number
Email Address
Prenatal Referral for Pregnant Person
Please fill this section if you are currently pregnant or are referring a person who is currently pregnant.
Name
First Name
Last Name
Estimated Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pregnant Person's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Earliest Prenatal Care
0-3 Months
4-6 Months
6-9 Months
No Prenatal Care
Unknown
First Child?
Yes
No
Please let us know if you have any specific questions or concerns.
Child Information
Please fill in this section if you are referring a child.
Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Race / Ethnicity
Sex of Child at Birth
Male
Female
Other
When did Prenatal Care Begin
0-3 Months
4-6 Months
6-9 Months
No Prenatal Care
Unknown
Are there other children in the home?
Yes
No
Additional Children in the Home
Please include first name, last name, and date of birth.
Please let us know if you have any specific questions or concerns.
Referring Agency
Please fill in this section if you are an agency referring a family.
Name
First Name
Last Name
Agency
Email
Phone Number and Ext.
Is this a Child Welfare Protocol (CWP) referral?
Yes
No
Please provide a brief summary of the reason for the referral.
Consenting Parent / Caregiver Signature
By signing above, I give permission for the appropriate partner programs to contact me to offer more information and services available to me and my family. I consent to have referral information electronically stored and shared within the software systems used by CIDS and its affiliates including the STKOT Network of health and social service partners.
Referring Party's Signature (if applicable)
By signing above, I have attested that I have spoken to the consenting parent/caregiver about this referral and they have given me consent to have referral information electronically stored and shared within the software systems used by CIDS and its affiliates including the STKOT Network of health and social service partners.
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