Home visiting referral

Family Information

Mother's Name

DOB

HOMELESS-Contact referral source

Address

City

State

ZIP Code

Phone

Primary Language

Interpreter Needed?

Yes

Other Worker

First Time Parent

Yes

If no, list # of children

Infant < 2 Weeks Old

Yes

Currently Pregnant

Yes

If yes, list due date

MA Eligible

Yes

Ethnicity

Hispanic

Non-Hispanic

Unknown

Race

American Indian/Alaska Native

Black/African American

Asian

White

Native Hawaiian Pacific Islander

Multi-racial

Unknown

Infant's Name(s)

Sex

Male

Sex

Female

Weight

Crown-Heel Length

Infant DOB

PLEASE ANSWER ALL QUESTIONS

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

1. Marital Status

Status

Single

Separated

Divorced

Widowed

9. Late prenatal, no prenatal care, poor compliance

Prenatal care started after the 12th week of pregnancy, poor compliance (missed appointments or not following medical advice) or no prenatal care.

2. Partner unemployed

Pertains to spouse or partner who will be involved with mother and baby in such a capacity. If no known partner, then false.

Mom employed?

Yes

10. History of abortions

Two or more intentional termination of pregnancy or one ITOP within 12 months of current pregnancy.

3. Inadequate income or no info regarding income source

Inadequate income means Medicaid, employed without insurance or stated concerns about family finances by family.

11. History of psychiatric care

History of psychiatric care or active psychiatric care.

Dr.

4. Unstable housing

No home, uncertain of having home or questionable address, such as homeless shelter.

12. Abortion unsuccessfully sought or attempted

Abortion considered for this pregnancy.

5. No Phone

13. Relinquishment for adoption sought or attempted

Adoption considered for this pregnancy.

6. Education under 12 years

14. Marital or family problems

Marital or family problems refers to any indication of discord among family members as relevant to the parent.

7. Lack of support network

No immediate family (parents, siblings, partner or spouse)

15. History of, or current, depression

Self-reported or staff reported.

8. History of substance abuse

Excessive use of drugs or alcohol.

16. Referral per professional discretion (please explain below)

NOTES

Screen Date

Positive

Negative

Family Agreed to Referral

Yes

OK to text family

Yes

Referral Source (1)

Phone

Referral Source (2)

Phone

Check here if you would like to receive a copy of this form via email

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

Referral Instructions

**Please complete all required (*) fields.

Screening information may be obtained conversationally in person or by phone, or by reviewing mom’s medical chart.

If you determine a home visiting referral is to be made, be sure to obtain verbal consent.**

Office Use Only

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.

Assigned/Referred to

Date

PROGRAM

Hennepin Healthy Families

Hennepin Healthy Families check box

Nurse-Family Partnership

Nurse-Family Partnership check box

Family Ties

Family Ties check box

Short-term home visiting

Short-term home visiting check box

Other

Other check box

CONTACT

Date of first attempted contact

PARENT SURVEY

Date

Scores

Survey Number

Result

Postitive

Negative

PHN ASSESSMENT

Date Requested

Date Completed

Requested by

OPENED

Date

Client Number

CLOSED

Declined

Declined check box

No Contact/Response

No Contact/Response check box

Out of Services Area

Out of Services Area check box

Deceased Baby

Deceased Baby check box

Active in other HV Program

Active in other HV Program check box

CPS Status

CPS Status check box

Referred to

Referred to check box

Verify Panel

Verify Step

Home visiting referral

Referral Instructions

Please complete all required (*) fields. Screening information may be obtained conversationally in person or by phone, or by reviewing mom’s medical chart. If you determine a home visiting referral is to be made, be sure to obtain verbal consent.

**Please complete all required (*) fields.

Screening information may be obtained conversationally in person or by phone, or by reviewing mom’s medical chart.

If you determine a home visiting referral is to be made, be sure to obtain verbal consent.**