<p> Dakota County Referral to Family Health Home Visiting Fax to 651-554-6130 or Email referral to [email protected]</p><p>Referral Source/Phone: Date:</p><p>Name of clients/fami Race/ ly members Birth Date Sex Referral Reason Ethnicity being referred First name: M Initial Last name: M PG, EDD: Postpartum F</p><p>Low Birth Premature Other: M PG, EDD: Postpartum F</p><p>Low Birth Premature Other: M PG, EDD: Postpartum F</p><p>Low Birth Premature Other: M PG, EDD: Postpartum F</p><p>Low Birth Premature Other: Foster Parent/ Guardian Name (if not the parent): Family Address: cell Alternate Phone: cell home home Phone: Client may be contacted by: Phone </p><p>Text E-mail Cell Phone Carrier We may leave Recorded Client / family aware of referral: message Y N Message with person English Interpreter Needed First time parent: Language: Spanish Y Y N Other: N</p><p>DCPHD-FH-1053 (1/18) Comments: </p><p>Intake staff MA/Minnes processing PMAP Private Insurance ota Care only: PMAP # UCare yes no BCBS Carrier: ID: PMI # </p><p>HealthPartners PMAP # UCare Error: yes no Reference BCBS Carrier: source not ID: Client found PMI # Insurance HealthPartners Informatio PMAP # UCare Error: n yes no Reference BCBS Carrier: source not ID: found PMI # HealthPartners PMAP # UCare Error: yes no Reference BCBS Carrier: source not ID: found PMI # HealthPartners Open to other Dakota yes no E&EA PH SS:(worker name) County Programs Mother Primary/Re AP Par PP2WK PP3MO MVS-I MVS-C Other: ason Child Primary/Re GRW ASTH BDIS EHDI LEAD FAP MVS-I MVS-C Other: ason NSC NSC FH Referral Family Rapid Response Destinatio Health Child Passenger Safety WSC WSC FH n: Family Rapid Health Response </p><p>PH Doc #: Intake PHN: Pending: </p><p>DCPHD-FH-1053 (1/18)</p>