Referral Form Questions (English)

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Required format:

PW9wm9fCzNZ4gwXaE3FSXQG9gPTcsqkZ6Vok2EuoCfhHdArJcIQH92sxZzF9DUpsMd5uuUqSKSeTg9kHPaUUgCVd44BitUIyNixvVFHCkz9i4gG5gu

Nurse Family Partnership (NFP) Referral Form

Eligibility Requirements for Nurse-Family Partnership (NFP) Program:

•Pregnant for the first time
•Less than 28 weeks pregnant*
•Chelan/Douglas County Resident
•Eligible for Medicaid/Apple Health or WIC

*The nurse needs time to visit and obtain consent before their 28th week of pregnancy.

Chelan-Douglas Health District
200 Valley Mall Parkway, East Wenatchee, WA 98802
Community & Family Health: (509) 886-6400 | FAX (509) 343-3241 Email: nfp@cdhd.wa.gov

Client Name (Last, First, MI):

* must provide value

Date of Birth

* must provide value

M-D-Y

Street Address

* must provide value

Apartment/Unit #:

City

* must provide value

State

* must provide value

Zip Code

* must provide value

Phone Number

* must provide value

Phone Type

* must provide value

Cell

Home

Other phone

Ok to leave a message?

* must provide value

Yes

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Email address

Preferred mode of contact

* must provide value

Call

Text

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Preferred Language

* must provide value

If other, provide language

Emergency Contact (Last, First)

Emergency Contact Phone

Relationship to client

Is the emergency contact person aware of the pregnancy?

Yes

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Eligibility Criteria

* must provide value

Low income

First pregnancy

Under 28 weeks gestation

Chelan/Douglas County resident

Is the client aware of the referral?

* must provide value

Yes

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Referring Provider(s)

* must provide value

Referring Agency Practice/Facility/Division Name

* must provide value

Referring provider email

* must provide value

Referring provider direct contact number

* must provide value

Medical concerns/comments:

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Due Date

* must provide value

M-D-Y H:M

Next OB appointment date/time

M-D-Y H:M

If unable to contact, NFP nurse to meet at next OB visit?

* must provide value

Yes

reset

NFP Use Only - Notes/Date of Enrollment

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This program is supported in part by funding from the Washington State Department of Children, Youth & Families.

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