Family Health Referral Form

Interpretation services required in the following language:

Referral Source Information

Date of referral:(Required)

Referred by:(Required)

If other, please specify:(Required)

Referring Organization:

Name of Referrer:(Required)

Phone:(Required)

Email:(Required)

Parent/Caregiver Information

Name (First and Last):(Required)

Date of birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Telephone #:(Required)

Alternate Telephone #:

Relationship to child:(Required)

If prenatal, due date (EDB) :

Infant/Child Information

Name

First Last

Date of birth

Gender

Does the Child Reside in the Parent/Caregiver’s Home?

Yes

Do you want to add another child to this referral form? (2)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (3)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (4)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (5)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (6)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (7)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (8)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (9)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (10)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (11)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Do you want to add another child to this referral form? (12)(Required)

Yes

Name(Required)

First Last

Date of birth(Required)

Gender(Required)

Does the Child Reside in the Parent/Caregiver’s Home?(Required)

Yes

Referral Type

Please select referral type

Check all that apply

If other, please specify(Required)

Additional Agencies

Is the Patient/ Client presently involved with other Agencies?(Required)

Yes

Check all that apply(Required)

If other agency, please specify

Worker Safety Risk

Is worker safety risk present?(Required)

Yes

Safety Recommendation (if worker safety risk is present)(Required)

Joint Visit with CAS

Consult with CAS worker prior to first visit

Other

If other, please specify(Required)

Additional Safety Recommendation Comments

If you have additional questions please contact the Family Health Line 519-383-3817. A public health nurse is available Monday to Friday 8:30a.m. – 4:30p.m.

The information in this form is being collected, used, and disclosed subject to the Health Protection and Promotion Act (Ontario), the Health Cards and Number Control Act, 1991 (Ontario) and the Personal Health Information Protection Act, 2004 (Ontario). Personal information contained on this form is collected ) for the purpose of identifying individuals that require referral services to local resources, and statistical reporting (i.e., evaluating current resources and planning for future use of those services) and service provision by Lambton Public Health. Any questions regarding the collection, use and disclosure of this information may be directed to Lambton Public Health at 519-383-8331 or toll free 1-800-667-1839.