AT – RISK INFANT INTAKE SHEET
POLK COUNTY [pic]
HEALTHY START REFERRAL
PATIENT INFORMATION
1. MOTHER:
Name: ________________________________ Social Security #: ____________________ DOB: _________________
Age: __________ Race: _______________ Address: ____________________________________________________
City: _________________________________ Zip: _____________ Phone Number: ________________________
Contact Name: ___________________________________ Phone #: ________________________________________
Address: ________________________________________ Zip: ______________ Prenatal Care (Y or N): _______
Place: ___________________________________ No. of Visits: ________ Trimester Care Initiated: _______________
2. INFANT:
Name: ________________________________________________ Sex: ___________ Race: _____________________
Hospital of delivery: ______________________________________________________ DOB: ____________________
Birth Weight: _______________________________________ g.) Birth Length: _______________________________
Health Problems/Special Equipment or Needs: __________________________________________________________
3. REASON FOR REFERRAL:
Cocaine: ________ Alcohol: ________ Marijuana: ________ Amphetamines: ________ Poly Drug Use: _________
Other (abuse/neglect/etc…):_________________________________________________________________________
4. EVIDENCED BY PRESENCE IN:
Infant: _________ Mother: _________ History of Use: _______________________ Other: ______________________
Date of positive drug screen: _________________ Referral done for substance evaluation? _______________________
Agency referred to: _________________________________________________________________________________
5. EXPECTED DISCHARGE DATE:
Mother: _________________________________________ Infant: ___________________________________________
6. PROTECTIVE INVESTIGATOR:
Name: ________________________________________ Phone (work): __________________ Cell: _________________
Fax: ______________________ Supervisor’s name: ______________________________________Phone: ___________
Case number _________________________________
7. PROTECTIVE SERVICE WORKER:
Name: ______________________________________ Phone: ________________________ Cell: __________________
Fax: _________________________
8. PLACEMENT:
Home: _____________ Foster Care: _____________ Shelter: _____________ Relative: ___________ Other: __________
Guardian’s name: ___________________________________ Relationship: _____________________________________
Address: __________________________________________ City: ____________________________ Zip: ___________
Phone: _________________________________
9. OTHER REFERRAL AGENCIES:
Healthy Families: __________________ Family Builders: ____________________ Other: _________________________
Contact Healthy Start Care Coordinator according to area where child will reside (see attached staff list).
Referred by: _______________________________________ _______________________________________________
Print Name Sign and Date
Telephone: _________________________________________ Agency:_________________________________________
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