Family stressors (Check all that apply)


Medical Provider Information


To make a referral for home visiting services, click "Submit"

  • All fields are required.  
  • Do not change any of the field names within this panel.
  • If user entered values are used to complete one of these fields - that must be done via code.
  • All code for each field is found in the calculate event.
General settings

A dropdown is used - just in case you change these values when in different environments.

This is used to fill in the body of the email.  Something like "NOK Authorization for Removal" or "Tab Renewal"

Note: Make sure to add  '.pdf' to your filename

Email settings - submitter

This value will normally be the email address of whomever is submitting the form.  You can set this value to a value entered by the user.

This value may be the same as the 'email subject - LOB'.  Just code - or copy/paste the value as needed'

Email settings - LOB

This value will normally be the email address of an LOB general mailbox.  Something like: ME.Operations@hennepin.us  

Only one email per field.

(cc)

This value will normally be the email address of an LOB general mailbox.  Something like: ME.Operations@hennepin.us  

Only one email per field. 

If this value should be left blank - noreplay@hennepin.us should be used as the default.  

This value may be the same as the 'email subject - submitter'.  Just code - or copy/paste the value as needed'

  • Double check all of your settings to make sure the emails will look correct when sent.
  • Make sure to hide this panel before sending for review.

Office use only

Screening instructions 

1. Completing the Screen

  A. Screening information may be obtained:

       1. Conversationally in person or by phone: OR

       2. By reviewing Mom's medical chart. 

  B. Answer all 16 items as either (T) - TRUE, (F) - False, or (U) if UNKOWN or UNABLE to ascertain truth value 

2. Scoring the screen

  A. Positive screen:

      1. #1, 9 or 12 are TRUE; or

      2. Any two items on the screen are TRUE; or

      3. There are 7 or more unknowns

  B. Negative screen

      1. #1, 9 or 12 are FALSE; or

      2. No more than one item is TRUE; or

      3. There are less than 7unknowns. 

IF SCREEN IS POSITIVE, OFFER THE PARENTS THE PARENT SURVEY VISIT.  

 

PROGRAM

CONTACT

PARENT SURVEY

Scores

PHN ASSESSMENT

OPENED

CLOSED

Verify Step