AddPublicReferral - Ingham MCH

Maternal and Child Health Home Visiting Referral Form

This is a referral for home visiting services through the Maternal Child Health Division at the Ingham County Health Department. This form may be completed by prospective clients or by referring agencies. All services are voluntary, and staff use the information provided to best connect individuals with one of our home visiting programs. Once complete, the referral will be reviewed and assigned to a home visitor, who will contact the individual within three to five days.

Date of Referral

Person Completing Referral

Referral completed by client Referral completed by another party

How did you hear about this program? (Check all that apply).

Referral from Healthcare Provider

Referral from Agency

Referral from Friend/Current Client

Website

Name of Website

Social Media

Other

Other Specify:

Client Information

Client First Name

Client Last Name

Client Date of Birth

Client Gender

Client Race/Ethnicity
(Select all that apply)

American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Other
Declined

Primary Language Spoken in Home

Interpreter Needed?

Yes No

Client Address/Contact Information

Street

City

State

County

Zip

Home Phone

Cell Phone

Accepts Texts Messages?

Yes No

Additional Contact Information

First Name

Last Name

Phone Number

Relationship

Other Parent/Guardian of Child
Parent of Client
Friend
Other

Client Medical Information

Client Current Status (check all that apply):

Pregnant
Parenting
Other

Estimated Due Date (if pregnant)

Number of Previous Pregnancies
(Don’t include current pregnancy)

Number of Previous Deliveries

History of Preterm Delivery?

Yes No

History of Low Birth Weight?

Yes No

History of miscarriage/fetal loss?

Yes No

History of Infant Loss up to One year of Age?

Yes No

Client Health Care Provider Information

Provider Office

Physician First Name

Last Name

Physician Phone Number

Insurance Information

Health Insurance Type (select all that apply)

Select Medicaid Health Plan

Child Medical Information

Child Medical Information Record added successfully!

Child Medical Information Record deleted successfully!

Child Medical Information Record updated successfully!

Updating Child Medical Information Record...

Child First Name

Child Last Name

Child Gender

Child Date of Birth

Child Medicaid ID#

Child Race/Ethnicity

American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Other
Declined

Birth Weight Pounds

Birth Weight Ounces

Current Weight Pounds

Current Weight Ounces

Provider Office

Physician First Name

Physician Last Name

Physician Phone Number

Add Child Medical Information

Update Child Medical Information

Associated Children Medical Information

First Name	Last Name	Date of Birth	Gender	Actions

Notes

Referral Document Upload(s)

Upload New File(s) - Files types are limited to: Images(png, jpg, gif), PDF and Word (docx, doc) files (File size limited to 5MB)

Program(s) Assignment

Program	Date of Assignment	Date of Enrollment	Date of Closure
FOS	FOS Date Assigned	FOS Date of Enrollment	FOS Date of Closure
MIHP	MIHP Date Assigned	MIHP Date of Enrollment	MIHP Date of Closure
NFP	NFP Date Assigned	NFP Date of Enrollment	NFP Date of Closure
SSHS	SSHS Date Assigned	SSHS Date of Enrollment	SSHS Date of Closure
CSHCS	CSHCS Date Assigned	CSHCS Date of Enrollment	CSHCS Date of Closure

Referral Status

Status Closed Reason

Reason for Rejection

Client Name	Date Enrolled	Healthy Start Status	Date Changed	Changed By