Early Head Start Referral Form
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2Branch County Prenatal & 0-5 Services
Early Head Start, Family Success Program, & Early On
Referral Form
Office use Only:
Referral Date ____________________
______________ Date Contact made w/family
Mother’s Name:
Phone: ___________
____
Father’s Name:
Phone:
_______
____
Address:
____
Prenatal: (Circle one):
YES
NO
Due Date: ___________________________
Child’s Name:
_____________ DOB:
____ # of weeks premature: _____
Child’s Name:
__________ _ DOB:
_______ ___# of weeks premature: _____
Child’s Name:
_____________ DOB:
____ # of weeks premature: _____
Parents (DOB): MOB___________________ FOB______________________
Best time to contact (Circle one):
AM
PM
Evenings
Best way to contact (Circle one):
Phone
Mail
E-mail address_____________________
_
Does child have insurance? (Circle one):
YES
NO
Is child on Medicaid? (Circle one):
YES
NO
If this a Non-English speaking household, what is the family’s primary language? ________________
Reasons for referral or concerns. Please check all that apply:
1. ____ ^ Homeless
2. ____ Lack of stable housing (not homeless)
3. ____ ^ Teen parent; pregnant Teen
4. ____ Child Birth / Labor Delivery / Breast feeding
5. ____ Late prenatal care
6. ____ Low Birth Weight
7. ____ * Developmental Delay or Concern _____________
8. ____ * Language delay or concern
9. ____ * Nutritionally deficient or concerns (overweight / underweight) that can impact
development
10. ___ * Diagnosed handicapping condition/least restrictive setting with support
11. ___ * Hearing, vision or sensory concerns
12. ___ * Long-term or chronic illness of child, health diagnosis or congenital anomaly
13. ___ * Medical concerns, premature, Illness or disorder, or an established medical
condition that can impact development
14. ___ Chronically ill parent/sibling (physical, mental or emotional)
15. ___ ^ Low family income
16. ___ Single parent
17. ___ Incarcerated parent
18. ___ Parental / sibling loss by death, divorce, or foster care
19. ___ Parenting skills lacking (setting limits, guiding behaviors, discipline
nd
Please complete the 2
page
C:\Users\metcalfc\Desktop\0-5 Referral form.doc
12/11/12ll
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