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.

Which nursing service are you requesting (descriptions below)? *

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.

Referring Agency or Self Referring *

0/200 characters

Referrer Name (First & Last) *

Referrer Email *

Referrer Phone *

The family knows I am making this referral. *

Yes

No

When the family is contacted, please contact me by: *

Phone

Email

Do Not Contact Me

Mother's Information

Full Name

First Name *

Last Name *

Date of Birth * +

Address

Street number and name *

Homeless? *

Yes

No

Zip *

Phone *

Email

Race/Ethnicity

Pregnancy Information

Pregnancy

I am pregnant and this is my first pregnancy.

I am pregnant and this is NOT my first pregnancy.

I recently delivered my baby.

Trimester (if pregnant)

1st (1-13 weeks).

2nd (14-27 weeks).

3rd (28-40 weeks).

Due Date +

When did you begin prenatal care?

1st Trimester.

2nd Trimester.

3rd Trimester.

I haven't begun prenatal care.

My OB's Name

Complete this section only if you already delivered your baby.

Baby's Date of Birth +

Delivery

Vaginal Delivery

C-Section Delivery

Baby's birth weight

Baby's gender

Boy

Girl

Feeding

Breastfed

Bottle Fed

Breast and Bottle Fed

Other Information

My Medical Insurance is:

Medicaid

Private

Other

None

If you need an interpreter, what language?

Select any of the following that apply to you:

Additional Comments