Public Health Nurse Referral

Thurston County Public Health Department is committed to protecting the confidentiality of your medical information, and the law requires us to do so. Read the complete Notice of Privacy Practices.

Nurse Family Partnership - Nurse home visiting designed for first-time moms less than 28 weeks pregnant at time of referral. This program follows baby until 2nd birthday.
Maternal & Child Health Services - Our Public Health Nurses offer preventative health services, early intervention assessments, and referrals for children with special health and developmental needs or those at risk for abuse or neglect.
Family Intervention Nurse - This program helps families who are in the postpartum period up to the child's first year of life.  Parents in the program receive home visits by a nurse with specialized training.
Children and Youth with Special Health Care Needs – offers services to children who have physical, behavioral or emotional conditions that require health and related services beyond those generally required by children.

Complete this section only if you are referring someone other than yourself.

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The family knows I am making this referral. *
When the family is contacted, please contact me by: *

Mother's Information

Full Name
Homeless? *

Pregnancy Information

Trimester (if pregnant)
When did you begin prenatal care?

Complete this section only if you already delivered your baby.

Baby's gender

Other Information

My Medical Insurance is:
Select any of the following that apply to you: