Agency referral

Child/Children

First Name

Last Name

Date of Birth

Parent(s)

The Child and Teen Checkups Program is a preventive health care program for children, youth, and young adults from birth through age 20 on Medical Assistance.

Check all that apply

Are you (if under age 21) and your child(ren) …

Do you need help...

Does your child need a well child checkup for… 

Do you have questions about your health plan such as:

Client/Self referral

Child/Children

First Name

Last Name

Date of Birth

Parent(s)

The Child and Teen Checkups Program is a preventive health care program for children, youth, and young adults from birth through age 20 on Medical Assistance.

Check all that apply

Are you (if under age 21) and your child(ren) …

Do you need help...

Does your child need a well child checkup for… 

Do you have questions about your health plan such as:

SCHW event referral

Child/Children

First Name

Last Name

Date of Birth

Parent(s)

Contact type

Contact detail