Home visiting referral

Family information

Caregiver name

Date of birth

Homeless-contact referral source

Address

City

State

ZIP Code

Phone

Phone number2

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

What is this person's gender? (Check all that apply)

Female

Male

Non-Binary

Additional identity (please specify)

Does this person consider themselves to be transgender?

Yes

I do not know

Pronouns

She-Her-Hers

He-Him-His

They-Them-Theirs

Prefers not to say

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)

Gender

Male

Female

Weight

Infant date of birth

Reason for referral

Antepartum/pregnant

Postpartum/new baby

Children with health concerns (e.g. asthma, lead, premature birth)

Safety (pack and play request)

Father program

Family stressors (Check all that apply)

Unstable housing

Low-income

Mental health concerns

Substance use

Single parent

Socially isolated

Recent immigration

Medically complex pregnancy

What are the family’s goals for family home visiting services?

Medical Provider Information

First name

Last name

Credentials

Clinic name

Clinic Street Address

Clinic Phone

Today's date

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"

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

No reply email address

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

Submission title/process

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

DoR file name (include '.pdf')

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

Email settings - submitter

Email address - 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.

Email subject - submitter

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

Email body - submitter

Email settings - LOB

Email address - 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.

Email address - LOB (cc)

(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.

Email subject - LOB

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

Email body - LOB

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

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

Survey Number

Result

Postitive

Negative

PHN ASSESSMENT

Date requested

Date Requested

Date completed

Date Completed

Requested by

OPENED

Date

Client number

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