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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