Looking for a Wic Referral Form Templates? Download it for free!

Ready To Change Childhood Obesity Prevention And Intervention Project Referral Form - Wake County Human Services

(919) 212 -7558

Please Fax Form to:

919-250-3068

Attn: Sharon Dawkins

Attn: Nutrition Center

Wake County Human Services WIC Program

Ready to Change Childhood Obesity Prevention and Intervention Project

Referral Form

Who is Eligible for WIC Services?

Pregnant and postpartum women, infants, and children birth to age 5 who meet income

eligibility requirements (Medicaid, Food and Nutrition Services [formally known as Food

Stamps], or Temporary Assistance for Needy Family participants are automatically eligible).

Ready to Change Classes:

As part of the WIC Program, nutrition and exercise group education classes are offered in

English and Spanish. These Ready to Change classes are offered to all WIC participants and

are also available to non-income eligible children between 1 and 5 years. Use this referral form

or contact the agency representative for more information:

Sharon Dawkins, MPH, RD, LDN

Wake County WIC

10 Sunnybrook Road, Raleigh, NC 27612

10 Sunnybrook Rd, Raleigh, NC 27610

Phone: (919) 250-4728 / Fax: (919) 212-7558

Phone: 919-250-4720 / Fax: 919-250-3068

Name of Client: _________________________________________________________________

Name of Parent/ Caretaker: _______________________________________________________

Street Address: __________________________________________________________________

City: _____________________ County: ______________ State: ________ Zip: _____________

Phone: ( ___ ) ____ - _______ DOB: ____ / ____ / ____ Age*: _____________ *

must be < 5 years

I, ___________________________________, grant permission for the information provided

on this form to be given to the representative of the referred agency.

Referring Agency: ______________________________________________________________

Date of Referral: ____ / ____ / ____

Reason for referral / Diagnoses: ___________________________________________________

______________________________________________________________________________

Follow-up Report

Agency Use Only:

Date Received:

Date client was contacted:

_____ / _____ / _____

WIC Eligible:  Yes  No On WIC:  Yes  No

Scheduled for RTC:  Yes  No Class Date: ____ / ____ / ____

WIC / RTC Referral Form, 10/08, 02/12

Ready To Change Childhood Obesity Prevention And Intervention Project Referral Form - Wake County Human Services