Home Visiting Referral Form

Date of Referral:

YYYY

Client Name:

Client Date of Birth:

YYYY

Client Address:

Email Address:

Phone

Preferred method of communication:

Client prefers text

Client prefers phone call

Client prefers email

Is the client currently pregnant?

Yes

Additional information about client and their family (choose any that apply):

Client's first pregnancy and they are LESS THAN 28 weeks pregnant

Client's first pregnancy and they are MORE THAN 28 weeks pregnant

Client is pregnant, but this is not their first pregnancy

Client has a baby under 3 months of age

Client has additional children between 3 months to 3 years of age

If client is currently pregnant, what is the estimated due date:

YYYY

If client is not currently pregnant, please enter the child's name and date of birth:

Primary Language:

English

Creole

Spanish

Other:

Race:

African American

Caucasian

Native American

Asian

Hawaiian/Pacific Islander

Other:

Biracial

Hispanic

Marital Status:

Single

Married

Separated

Divorced

Widowed

If referral is under 18, please provide the name of a parent or legal guardian:

Relationship to client:

Is it OK to contact this person in reference to this referral?

Yes

Does client receive any of the following? (check all that apply)

Medicaid

Food Stamps

TANF

WIC

If client receives Medicaid, please indicate Medicaid provider:

Highmark

Amerihealth Caritas

Centene

Medicaid ID# (if applicable):

Some potential risk factors for consideration to make a referral (Please check all those that apply):

Teen parent

Low income

Child abuse/neglect

Child w/disability or chronic health condition

Recent immigrant or refugee family

Death in the immediate family

Parent w/disability or chronic health condition

Substance use disorder

Foster care or other temporary caregiver

Parent w/mental health issues

Very low birth weight

Military deployment

Low educational attainment

Intimate partner violence

Parent incarcerated during the child's lifetime

Housing instability

Unsure/None of the above

Is the client being referred involved with DFS?

Yes

If yes, is there a Plan of Safe Care (POSC) in place?

Yes

N/A

Name of person/agency making referral:

Email:

Phone