<p> Children DIRECTIONS: Please complete form on every child, birth to age 5, 1st having any of the conditions listed Screening and on 1st or 2nd page. Check or fill in Referral Form as much information as possible. Send form to Referral Source: local Children 1st Coordinator. Date Received: SECTION A CHILD AND FAMILY INFORMATION CHILD’S INFORMATION MOTHER’S INFORMATION Child: Mother: Last Name First MI Last Name First MI Date of Birth: Birth weight: Maiden Sex:  Male  Age: Date of Birth: Female  Unknown Gestational Age: Education: (last Select race: grade completed) (Mark all that apply) Marital Status:  M  NM  SEP  White  Black or African  D  W Live in American Partner:  Yes  No  Asian  American Indian or Prenatal Care:  1st  2nd  3rd  Alaska Native None  Unknown  Hawaiian/ Parity G: P: Pre-Term: AB: Other Pacific Islander Latino/Hispanic: Elective/Spontaneous / Yes No  Unknown Parent’s Medicaid #: </p><p>Hospital: Discharge Date: FATHER’S INFORMATION Transfer Hospital: Discharge Date: Type of  Medicaid   Priv Last Name First Insurance: PeachCare ate MI  WellCare  Tri- GUARDIAN/FOSTER CARE REFERRALS CMO Car  Amerigroup e CMO  Non e  PeachState CMO  Unknown </p><p>Child’s Insurance #: (if known) Guardian/Foster Parent Last Name First Phone Number LANGUAGE NEEDS </p><p>Primary Language: Translator/Interpreter DFCS Case Worker Last Name First Phone Number Needed:  Y  N Fax Number CHILD’S PRIMARY MEDICAL/HEALTH CARE PROVIDER CONTACT INFORMATION Child Lives with:  Mother  Father  Guardian  Foster Parent Name Child’s Address: Street /Route Apt Complex # / Mobile Hm Street or Route Park# City State Zip City County Zip Phone #: Emergency Contact #: Caregiver email address: Phone Fax SECTION B HOSPITAL INFORMATION Newborn Hearing Screening:  Not Screened Equipment:  Family Refused Screening Vaccines Given During Hospital Stay:     Inpatient: Date: / / Left: Pass Refer Right: Pass Refer Hepatitis B Vaccine:  AOAE  AABR  Other (date) Outpatient: Date: / / Left:  Pass Refer Right:  Pass  Refer  AOAE  AABR  Other HBIG: (date) Newborn Bloodspot Metabolic Screening:  Not Screened  Family Refused Screening SECTION C LEVEL 2 RISK CONDITIONS (3 OR MORE MUST BE PRESENT FOR ELIGIBILITY) Conditions Child Abuse Prevention Treatment Act Identified at Birth (CAPTA) 655.4  Suspected damage to fetus All CAPTA referrals are automatic referral (Child age (Mother Smoked and/or birth to 3 years) Drank, > 7 drinks/week, V60.81  Foster Care during Pregnancy) 995.5  Child Maltreatment Syndrome 765.16-765.18  Disorders r/t other preterm (Substantiated Case) infants <2500 Grams DFCS Referrals (no CAPTA) (5 lbs. 8 oz.) and > V60.81  Foster Care (over age 3) 1500 Grams 995.5  Child Maltreatment (Substantiated Case) V23.7  Insufficient Prenatal Care (Little (over age 3) or no prenatal care) V23.83-V23.84  Young V61.05  Unsubstantiated or sibling of victim of Prima-/Multi-gravida (Maternal Age <18 years) substantiated case (birth to 5) V62.3  Education C1MD.1  Child under age 5 exhibiting physical or Circumstance developmental delay s (Maternal Education <12 Years) Socio-Environmental Conditions Present in the Family V17.0  Psychiatric condition (Parental Mental Illness, Depression) V18.4  Mental Retardation (Parental Mental Retardation) V60.0  Lack of Housing (Homelessness) V60.2  Inadequate Material Resources (Affecting Care of Child) V61.05  Family disruption due to child in welfare custody V61.2  Parent-Child Problems (Questionable Mother/Child Attach) V61.5  Multiparity - in Mother (<20 Years of age, >3 pregnancies) V62.0  Parental Unemployment V62.5  Legal Circumstances (Parental Incarceration) V62.8  Other Psych. or Physical Stress, (History of Family Violence) V16-V19  Family History of (Specify) (Illness/disability affecting care of child) C1SEC.1  Child Injuries (>3 in 1 Year) Requiring Medical Attention Specify: SECTION D SIGNATURES</p><p>Name of Person Completing Form Agency Email Address Phone Date Parent Signature (Encouraged but not required for referral) Parent Informed of Referral?  Yes  No Form #3267 Page 1 of 2 Child’s Name: Mother’s Name: SECTION E (check all that apply) LEVEL 1 RISK CONDITIONS (Medical/Biological Conditions Present in Child Indicating Referral to Public or Private Sector Care) Infectious and Parasitic Diseases Conditions Originating in the Perinatal Period 042  HIV 760.71  Fetal Alcohol Syndrome 090  Syphilis 764.00  Light-for-dates infant without fetal malnutrition Mental Disorders unspecified (birth weight < 10% for 299.00-299.01  Autistic disorder gestational age) 315.3  Developmental speech or language disorder 764.9  Fetal Growth Retardation 315.9  Unspecified delay in (Intrauterine Growth Reduction- development C1MD.1  Suspected IUGR) Developmental Delay 765.01-765.03  Disorders r/t extreme immaturity of infant (BW < 999 gms) 765.14-765.15  Disorders r/t other preterm Endocrine, Nutritional & Metabolic Diseases, and Immunity Disorders infants (BW 1000-1500 gms) 243  Congenital hypothyroidism 767.0  Subdural and cerebral hemorrhage due to 27X.X X  Disturbances of amino-acid birth trauma metabolism (Metabolic disease) 768.5  Severe birth asphyxia (APGAR < 3 at 5 Specify(code, diagnosis): Minutes) 770.7  Chronic Respiratory Disease in perinatal Diseases of the Blood and Blood-Forming Organs period 282.X  Hereditary hemolytic anemias (Broncho-pulmonary Dysplasia) Specify(code, diagnosis): 770.81 or 770.82  Primary apnea or other apnea in Diseases of the Nervous System and Sense Organs newborn 320  Meningitis, Bacterial 770.9  Unspec. Respir. Condition of fetus/newborn 321  Meningitis, All Other (vent > 48hrs) 323.9  Encephalitis 771.0  Congenital Rubella 343.1-343.9  Infantile cerebral palsy 771.1  Congenital cytomegalovirus infection (CMV) 345  Epilepsy/Seizure Disorder 771.2  Other congenital infection in 348.3  Encephalopathy perinatal period (Herpes Simplex- 356-359  Neuromuscular Disorder congenital, Toxoplasmosis) 362.26 or 362.27  Retinopathy of Prematurity (Grades 4 or 772.13 or 772.14  Intraventricular Hemorrhage (IVH), Grade 5) III or IV 369.XX  Blindness and low vision Symptoms, Signs and Ill-Defined Conditions Specify (code, diagnosis): 783.4  Failure to Thrive/Growth 382.9  Unspecified otitis media – Deficiency (growth below chronic (recurrent or 5th %) persistent) 796.4  Other abnormal clinical findings 389.XX  Hearing Loss Specify(code, diagnosis): Specify(code, diagnosis): Serious Problems or Abnormalities of Body Systems Injury and Poisoning 390 – 459  Heart/Circulatory 959.01  Other and unspecified injury to head System 460 – 519  Respiratory 984 .0-984.9  Toxic effect of lead and its compounds, System including fumes Lead Level > 20 µg/dl 493  Asthma (Venous) 520 – 579  Digestive System Specify: 580 – 629  Genito-Urinary System Lead Level > 10 <20 µg/dl 710 – 739  Musculoskeletal System and (Venous) Specify: Connective Tissue 740 – 759  Congenital C1INJ.1  Ototoxic medications including chemotherapy anomalies 749  Cleft Palate/Lip Other Significant Conditions Specify Conditions for All Above (include Diagnosis V02.6  Carrier/suspected carrier of viral Code): hepatitis (Hep. B in Mom) V19.2  Family history of deafness or hearing loss V61.41 or V61.42  Alcoholism or Substance Abuse in Family (Maternal use of street, prescription or SECTION F REFERRAL CRITERIA LEGEND Health Department Staff: Please see eligibility lists for Babies Can’t Wait, Children’s Medical Services, 1st Care, Universal Newborn Hearing Screening, Genetics, and Lead Programs in order to appropriately refer children. SECTION G COMMENTS</p><p>Has child received a recent developmental screening ?:  Not screened  Yes, screened by (Please attach results) Measure used: Date screening completed Scores www.health.state.ga.us/programs/childrenfirst (Rev 6/2012) Form #3267 Page 2 of 2</p>