Visitation Referral Form

Eligible referrals must meet all of the following:
Be first time parent
Be prenatal mother, or infant up to 3 months of age
Meet at least one additional eligibility criteria listed in the section below

Additional Eligibility Criteria (Must have at least one additional criteria from the list below)

1. Parenting on own	5. Unstable housing	9. History of psychiatric care
2. Mother under 18 years of age	6. No phone	10. Marital or family problem
3. Late (after 12 weeks) or no contact with physician before delivery	7. Limited family or social support	11. History of depression or current depression
4. lnadequate income	8. History of substance use	12. History of family violence

Referral For
Mother's Name
Address
City
Postal Code
Phone Number
Alternate Phone

Mother's Information

Date of birth		Doctor's name
Expected Delivery Date		Date of first Doctor's Visit
Mother is on Health for Two	No Yes	Health for Two Site

Infant's Information Prenatal Postnatal


Referral Type	Self referral Professional
Referred By		Date of Referral
Site		Phone	Fax
Individual is aware of and has agreed to be contacted by home visitation worker				No Yes
Call referral person before contacting family				No Yes
Notes

Infant's Name	Infant's Sex	Male Female
Date of Birth	Gestation (#weeks)
Birth Weight (g)	NICU	No Yes
Length of Stay	Pediatrician