Santa Clara County Social Services Agency Department of Family and Children’s Services REFERRAL TO PUBLIC HEALTH NURSING

Please submit referral to CHDP Clerical on 5th Floor at 373 W. Julian or By email to CHDP Clerical ([email protected]) or by fax to: (408)792-1415

Children Referred to Public Health Nursing DFCS Case No. Child’s Name Date of Birth Current Caregiver Caregiver Information (First, Middle, Last) (Name street address & telephone number) 1. Mother Father Name: Relative/NREFM Address: City: Foster Parent Telephone #: Language 2. Mother Father Name: Relative/NREFM Address: City: Foster Parent Telephone #: Language 3. Mother Father Name: Relative/NREFM Address: City: Foster Parent Telephone #: Language 4. Mother Father Name: Relative/NREFM Address: City: Foster Parent Telephone #: Language YES NO Additional children are being referred (please continue on back of page).

Mother’s Name (First, Last) Birth Date Address Phone(s)

Birth Father’s Name (First, Last) Birth Date Father of: Address Phone(s) Additional fathers listed on back of page.

If Newborn, Name, City and State of Hospital where the Child was Born Reason for Referral Service Program Check all that apply & note # of Agencies Involved Check all that apply child from list above Growth/Dev. Concerns Voluntary Family Maint. EMQ SARC Premature Infant Informal Supervision MHD Early Start Infant Drug Exposed Family Maintenance Kidscope VMC Special Unmet Medical Need Reunification VMC Clinic Dr. Loo / IND Pregnant Teen Permanent Placement Lucille Packard CCS Obesity Head Start Other HV Services Asthma Gardner Diabetes Other Chronic Med. Concerns

Comments (Specifics of conditions checked above, reason for removal and/or additional information) Additional space on back

Submitted by:

SCZ1650(c).doc Filing: Fastener 5 Under Referral to Public Health Nursing – Rev. 3/11/2014 Page 1 of 2 Social Worker’s Name SW # Phone Fax Date Social Worker received Court authorization to make referral to the First 5 PHN Home Visitation Program & sign any associated consents & releases necessary. Additional Children in family being referred: 5. Mother Father Name: Relative/NREFM Address: City: Foster Parent Telephone #: Language 6. Mother Father Name: Relative/NREFM Address: City: Foster Parent Telephone #: Language 7. Mother Father Name: Relative/NREFM Address: City: Foster Parent Telephone #: Language

Additional Fathers for children in referral

Birth Father’s Name (First, Last) Birth Date Father of: Address Phone(s)

Birth Father’s Name (First, Last) Birth Date Father of: Address Phone(s)

Additional Information:

Action Taken by Public Health Nurse and Recommendations:

Public Health Nurse’s Name Phone Email Address Date

SCZ1650(c).doc Filing: Fastener 5 Under Referral to Public Health Nursing – Rev. 3/11/2014 Page 2 of 2