Maternal and Child Home Visiting Referral Form

If you feel a pregnant woman or family would benefit from home visiting or support, please fax this form to the First Connections agency in their community. See the back of this form for a listing. Name of Referrer: Agency / Program: Phone: __ __ __ - __ __ __ - __ __ __ __ Date: Position Title: Fax: ___ / ___ / ___

__ __ __ - __ __ __ - __ __ __ __ (signature Client consents to referral: Yes* needed) Email: If referring a pregnant woman younger than 18, complete her information in section 1 and her parent / guardians in section 3. Only provide street address in sections 2 and 3 if different from that listed in section 1. 1. Pregnant Woman / Parent / Guardian Information First Name: Birth Date: # of Other Children: LanguagePrimary: Street Address: Mailing Address (if diff.) Home Phone: Highest Education: Insurance Type: 2. Child Information First Name: Birth Date: Street Address: 3. Parent / Guardian of Minor Pregnant Woman Information First Name: LanguagePrimary: Street Address: Home Phone: __ __ __ - __ __ __ - __ __ __ __ Last: Preferred: City, RI Zip: Cell Phone: __ __ __ - __ __ __ - __ __ __ __ ___ / ___ / ___ City, RI Zip: Last: __ __ __ - __ __ __ - __ __ __ __ < high school (HS) Public None Private Some HS ___ / ___ / ___ Last: Currently: Due Date: Preferred: City, RI Zip: City, RI Zip: Cell Phone: __ __ __ - __ __ __ - __ __ __ __ Some/all college/advanced Pregnant ___ / ___ / ___ Homeless

HS diploma/GED Relationship to Child:

4.

Relationship to Pregnant Woman: Consent to Refer- Signature of Pregnant Woman / Parent and/ or Parent / Guardian of Minor Pregnant Woman _____________________________________________________________ __________________________ Signature Date *I hereby agree that information may be shared with the home visiting agencies listed on the back of this form and that I may be contacted by one of those agencies.

Please write additional comments about the referral anywhere on the front of this form.

How to refer: To refer pregnant women and families with young children to home visiting, please fax this form to the First Connections agency that serves the community where they reside. The First Connections agency will connect pregnant women and families with the home visiting program(s) available to them. Community Central Falls, Cranston Pawtucket, Providence Burrillville, Cumberland, Foster, Glocester, Johnston, Lincoln North Providence, North Smithfield, Scituate Smithfield, Woonsocket Charlestown, Coventry, East Greenwich Exeter, Hopkinton, Narragansett New Shoreham, North Kingstown, Richmond South Kingstown, Warwick, West Greenwich West Warwick, Westerly Barrington, Bristol, East Providence Jamestown, Little Compton, Middletown Newport, Portsmouth, Tiverton, Warren Agency Childrens Friend 401-721-6400 (phone) 401-724-9251 (fax) Family Resources Community Action 401-766-0900 (phone) 401-767-4099 (fax)

VNS Home Health Services 401-782-0500 (phone) 401-788-2064 (fax) VNS of Newport & Bristol Counties 401-682-2100 (phone) 401-682-2112 (fax)

Programs: There is an array of home visiting programs and resources available for pregnant women and families with young children. Home visiting programs will work with families to provide them the available programs and resources they want. First Connections Statewide Serves pregnant women and families with children, birth to age three. 1 3 visits are provided, more if necessary. Visits are based on needs of family and may include health education, finding a medical home, and connections with community resources. Enrolls pregnant women and families with infants younger than two weeks of age. Long-term program that provides visits until child is three years of age. Helps parents understand child development, improve well being, and be successful. Enrolls expectant first-time mothers before their 28th week of pregnancy. Long-term program that provides visits until child is two years of age. Provides parents support before and after the birth of their child; empowers families to set goals for themselves. Enrolls pregnant women and families with children through six months of age. Long-term program that provides visits until child is three years of age. Works with families to increase knowledge of their childs development and prepare them for school.

Healthy Families America Central Falls, Newport, Pawtucket, Providence, West Warwick, and Woonsocket Services provided by: Childrens Friend, East Bay Community Action, Family Resources Community Action, Family Service of RI, Meeting Street Nurse-Family Partnership Central Falls, Newport, Pawtucket, Providence, West Warwick, and Woonsocket

Services provided by: Childrens Friend Parents as Teachers Central Falls, Pawtucket, Providence, Woonsocket

Services provided by: Blackstone Valley Community Action Program, Connecting for Children & Families, Federal Hill House Questions? Call the HEALTH Information Line: 401-222-5960 / RI Relay 711 To order referral pads or outreach cards, visit www.health.ri.gov/forms/onlineordering/form_providers.php For more information, visit www.health.ri.gov/homevisiting Updated 08/26/2013