DPH Home Visiting Electronic Referral Form

Person Making Referral

This can be your name, if you are referring yourself.

Referral Source

Choose the best option from the choices.

Referral Source (if OTHER):

Name of Practice (if applicable)

This is not required for self-referral.

Phone Number (Practice, or Personal if self-referral)

Patient First Name

Patient Last Name

Patient Date of Birth (MM/DD/YYYY)

Please use: MM/DD/YYYY format

County of Residence

Currently this program is limited to Clarke, Elbert, Greene, Jackson & Oglethorpe counties.

County (if OTHER)

Patient Home Address (Number and Street, etc)

City

ZIP Code

Patient Phone Number

Alternative Phone Number (optional)

The following information is needed to determine eligibility and facilitate enrollment into the program:

Is patient currently pregnant?

If Pregnant, Number of WEEKS

If pregnant, is patient receiving prenatal care?

Estimated or Actual Delivery Date

Please use: MM/DD/YYYY format

Maternal Race/Ethnicity

If interpreter services are needed, please indicate which language(s):

Choose ALL that apply:

Maternal health indicators:

Infant health indicators:

NICU admission following birth

Low birth weight

Very low birth weight

Poor feeding

<36 weeks gestation at delivery

Positive maternal screening for substances at delivery

Notes/Comments/Additional Information

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