NOTE: to Qualify for the Region 1 Nurse-Family Partnership (NFP) Program, a Woman Must

NURSE-FAMILY PARTNERSHIP REFERRAL FORM

NOTE: To qualify for the Region 1 Nurse-Family Partnership (NFP) Program, a woman must:  Be less than 28 weeks pregnant  Have no previous live births  Be low-income  Live in targeted area/parish (Orleans, Jefferson, St. Bernard, Upper Plaquemines) An NFP nurse needs time to visit and obtain consent before the 29th week of pregnancy. Part 1 Part 2 Instructions: Complete and of form. Mail or fax to the patient’s nearest NFP location and notify the site if sending the referral via fax (HIPAA requirement). Date: / /

Part 1 Patient/Client Information

Name: Age: Birthdate # of weeks Pregnant: / / ConfirmedAgency/Practice with Pregnancy Name, Facility Test? or Division: LMP: Expected Delivery Date: Speaks English? If No, SpecifyDate: Language: / / □Disposition Yes , Date of Referral: / / □ No / / / / □ Yes □ No Address:□Address: 1. Enrolled in NFP Program Apt: Zip: Client MedicaidDate Number of Enrollment: Zip: /Placement / Date: / / Additional Address: Apt. Zip: Referring□ 2. Ineligible: Staff Name: □ >28 Weeks Pregnant □ Previous Live Birth Title:□ Unable to Locate □ Other, Specify:Phone #: Home Phone #: Work Phone #: Cell Phone #: Email address: □ 3. Refused to Participate: □ Yes □ No If Refused, Reason: To BeEmergency Comments:Completed Contact by Person: the Nurse-FamilyRelationship to Patient/Client: PartnershipContact’s Site Home Phone #: Work Phone #: Cell Phone #:

Patient agrees to be referred to NFP & provide the information above Patient’s/Client’s Signature: Date: regarding her pregnancy: □ Yes □ No / /

ReferringPart 2 Agency/Practice Information

Completed by NFP Staff: NFP Site: Date: / /

Nurse-Family Partnership Region 1 – New Orleans, Jefferson, St. Bernard & Upper Plaquemines Parishes Part 3 PHONE: 504-568-5926 FAX: 504-599-0161