01. Mahogany Project Referral Form

Mahogany Project Referral Form

Use this form to refer a pregnant or postpartum individual to the Mahogany Project. Submission of a referral does not guarantee program eligibility. Program staff will contact the potential participant to complete eligibility screening and enrollment, when appropriate.
Potential Participant Information
Potential Participant Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
If no email address, enter noemail@email.com
Preferred Method of Contact
Primary Language
Preferred Language for Communication
Race
Ethnicity
Pregnancy / Postpartum Information
Current Status
How many weeks pregnant are you?
Estimated Due Date (EDD), if known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How many pregnancies have you had prior to your current pregnancy?
Date of Last Delivery

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How many months is your infant?
How many pregnancies have you had prior to your most recent delivery?
Are you currently receiving prenatal or postpartum medical care?
Name of Current Prenatal/Postpartum Healthcare Provider or Clinic.
Please enter the actual name of the provider, practice, hospital, or clinic where prenatal or postpartum care is currently being received (e.g., provider or clinic name).
Secondary and/or Emergency Contact

Provide a trusted alternate contact Mahogany may use only if staff are unable to reach the potential participant.
Contact Name

First NameLast Name
Relationship to Potential Participant
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referral Information
If the potential participant is self-referring, select Self-Referral and the remaining referral-source fields may be left blank.
Referral Type
Referring Agency or Organization
Other Referral Source — Specify
Referring Person's Name
Referring Person's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Person's Email Address
example@example.com
Is the potential participant aware that this referral is being submitted?
About The Mahogany Project Services
The Mahogany Project provides Health Education, Case Management—including resource navigation, referrals, and service linkage—and Emotional Wellness/Counseling services. The program may assist participants with identifying and connecting to available community resources based on their individual needs. Participation in the program does not guarantee direct financial assistance, housing, payment of bills, incentives, or tangible items.
Reason for Referral/Interest & Identified Need(s) (Select all that apply.)

Other
Date Referral Submitted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mahogany Staff Use Only
Assigned Care Coordinator
Date Referral Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Initial Contact Status
Date of Initial Contact Attempt

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Eligibility Screening Scheduled?
Eligibility Screening Date, if scheduled

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referral Disposition
If referred elsewhere, resource/provider referred to
Staff Notes
Should be Empty:

Mahogany Project Referral Form

Potential Participant Information

Pregnancy / Postpartum Information

Secondary and/or Emergency Contact

Referral Information

About The Mahogany Project Services

Mahogany Staff Use Only