Home Visiting Referral


PLEASE ANSWER ALL QUESTIONS

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

 

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

 

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

 

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

 

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

 

History of psychiatric care or active psychiatric care. 

 

 

 

 

 

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

 

Abortion considered for this pregnancy. 

 

Adoption considered for this pregnancy. 

 

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

 

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

 

Self-reported or staff reported. 

 

Excessive use of drugs or alcohol. 

 

NOTES 

 

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

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