* are required fields.
Referral Source Information
Are you submitting a referral on behalf of yourself or someone else?
*
Myself
Someone else
Person Making Referral
Your Name
*
First Name
Middle Initial
Last Name
Best Phone Number for Contact
*
Are you an employee with Anoka County Social Services and Behavioral Health?
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Yes
No
Social Services Program Area
*
Upfront
Plan of Safe Care(POSC)
Voluntary Case Management
Ongoing Case Management
Permanency
Minor Parent Program
Other
Other
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Consult with referral source prior to contacting client?
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Yes
No
Notify referral source regarding outcome of referral?
*
Yes
No
Is there a signed release to Public Health Nursing on file?
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Yes
No
Are Public Health Family Home Visiting Services court ordered for this family?
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Yes
No
Type of Social Services Referral?
*
Standard Referral
Urgent Referral
Contact Public Health to speak with Nursing Supervisor on intake 763-324-4240
Agency
*
Referral Information
Primary Reason for Referral
Pregnancy:
Public Health Nursing home visits for pregnancy and ongoing support.
Postpartum/New Infant (under 8wks):
Public Health Nursing home visits for support during postpartum and beyond.
Parenting:
Public Health Nursing home visits for support with parenting and beyond.
Asthma:
Public Health Nursing home visit for child with asthma
Child & Teen Check-Ups:
One time home visit for support navigating MA and other resources.
Parenting Inside Out Class :
Parenting class for justice involved families.
Pregnancy Information
Do you know your due date?
*
Yes
No
Yes
*
Have parental rights been terminated?
Yes
No
Unknown
Currently parenting children
Yes
No
Unknown
History and/or current involvement with child protective services.
Yes
No
Unknown
How does parent meet criteria for Parenting Inside Out class?
*
(Select all that apply)
Currently serving sentence at the Anoka County Workhouse.
Currently on probation or supervised release through Anoka County Corrections.
Released from prison and currently residing in Anoka County?
Recently involved with a criminal court case that resulted in jail or prison stay.
Child has an open case with Juvenile Diversion.
Other
Name (Client or Self)
*
First Name
Middle Initial
Last Name
Date of Birth (Client or Self)
Have Phone Number?
*
Yes
No
Phone Number
*
Select Best Method to Contact
*
Okay to text
Okay to leave voice message
Okay to text or leave voice message
Not okay to text or leave voice message
Is client aware of referral?
*
Yes
No
Children
First Name
Last Name
Child DOB
Child Sex
Male
Female
Other
Unknown
Please specify where child is currently living if not with client/parent?
Add Children
Remove Children
Address
Housing Type
*
Own Home
Living with Others
Homeless/Shelter
Inpatient Program
Other
Other
*
No permanent address
Street Address
*
Apt/Unit Number
City
*
Zip
*
Language
Interpreter Needed
*
Yes
No
Interpreter Info
Interpreter Language
*
Arabic
Amharic
Burmese
Cantonese
French
Hmong
Khmer
Korean
Laotian
Mandarin
Oromo
Other
Russian
Serbo-Croa
Somali
Spanish
Swahili
Tigrinya
Ukrainian
Vietnamese
Yoruba
Other
*
Family Stressors
Family Stressor
*
(Select all that apply)
Unstable Housing
Low-Income
Mental Health Concerns
Substance Use
Single Parent
Socially Isolated
Recent Immigration
Medical Concerns
First Time Parent
Additional Information
Additional Information
*
Status
New
In Progress
Entered
Transferred
Referral Date
Additional Documents
Please indicate that you have documents to fax to (763)324-1033 by checking this box.
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For any questions or to speak to someone directly regarding the referral, call intake at 763-324-4240 or email Public.Health.Nursing@anokacountymn.gov
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