Perinatal Nurse Support Program Referral Form
Referring Provider Information
Name
First Name
Last Name
Organization
Date of Referral
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Reason for Referral. Check all that apply:
Pregnant with OUD/SUD
Postpartum OUD/SUD
MOUD support needed
NAS/SOWS infant
Relapse risk/recent use
Missed pernatal/postpartum care
Mental health concerns
Social instability (housing/IPV/legal)
Other
Client/Family Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is it ok to text or leave a voicemail to this number?
Yes
No
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Language
Interpreter needed?
Yes
No
Perinatal Status
Pregnant
Postpartum
Expected Due Date
-
Month
-
Day
Year
Date
Baby's Name and Birthday
Clinical Background
Primary Substance(s). Check all that apply:
Opioids (heroin, fentanyl, prescription opioids)
Methamphetamine
Cocaine
Alcohol
Cannabis
Tobacco/Nicotine
Benzodiazepines
Other
Current Use Status
Active use
Early Recovery (<90 days)
Sustained recovery
Unknown
Treatment Status
Currently in treatment?
Yes
No
If yes, who is the provider?
Is there a Plan of Safe Care completed?
Yes (attach below)
No
MOUD
Methadone
Buprenorphine
Naltrexone
Suboxone
Other
Consent
Client verbally consented to referral
Yes
No
Attach supportive documents as available (5Ps screening tool, PoSC, etc)
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