Public Health Nursing Referral Form

Prenatal and Postpartum

Call: (253) 798-6403 or Fax: (253) 798-3522

Referrer Info / Referral Date: / Agency:
Referrer Name: / Phone/Fax:

SERVICE REQUESTED

/ MSS ICM BHS Nutrition Lactation Nursing NFP BIH
IF REFERRAL FOR NURSE--FAMILY PARTNERSHIP (NFP), CLIENT MUST BE <26 WEEKS PREGNANT AT TIME OF REFERRAL AND MUST BE A FIRST TIME MOM.
I would like to be notified when you follow up on this referral: No Phone Fax
Client Info / Mother’s Name (last, first) Race: / DOB/Age:
Address: / City: / Zip:
Phone #: / Email:
Pregnancy EDD: / 1st Preg. / Prenatal Care: 1st Tri 2nd Tri 3rd Tri
Delivery Date: / NSVD C-Section / Breast Bottle Both
Infant/Child Name: / DOB/Age: / M F
Risk Factors / Race
Prenatal Care
Food Insufficiency
BMI
Pregnancy Intervals
Diabetes
Multiple Births
Hypertension
Low Birth Weight
Maternal Age
Use Tobacco
Drugs/ETOH
Mental Health Issues
Developmental Delay
Domestic Violence
Other / Insurance: DSHS Private None / Medicaid – Provider One #:
Is mother aware of referral: Yes No / Receptive: Yes No
Homeless
Lacks skills
Bonding issues
No support / Comments:
TPCHD Use / Assigned Referral Date: / PHN Assigned:
By: Client ID #:

Created 2/27/2012- Revised 6/19/13

G\Libshare\FSP_Common\NFP\Forms\PHN Referral Form G\Libshare\FSP_Common\Nursing\PHN Referral Form