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ALPINE COUNTY HEALTH DEPARTMENT Ph: [PHONE REDACTED] / Fx: [PHONE REDACTED] 75 B Diamond Valley Road Markleeville, CA 96120 2/1/2018 REFERRAL SOURCE Referred By Agency Would you like updates about the status of this referral? Yes No If yes, Contact Information: Phone Is client aware of referral? Yes No Email PATIENT INFORMATION Last Name First Name Date of Birth Preferred Name/Nickname Address City Zip Code Phone Number Alternative Phone Number Preferred Language Medi-Cal # Grava Para EDC Delivery Type Prenatal Care Provider INFANT / CHILD INFORMATION Last Name First Name Date of Birth Gender Birth Weight Birth Height HC GA at Birth Primary Care Provider REASON FOR REFERRAL At Risk / Suspected / Known [ ] First Time Mom / Teen [ ] Infant / Child Feeding Problems [ ] Inconsistant / Late - Entry or No Prenatal Care [ ] Growth and / or Developmental Concerns [ ] Maternal / Postpartum Mental Health Concerns [ ] Premature Birth [ ] Substance Abuse [ ] Substance Exposure [ ] Domestic Violence / Unhealthy Relationships [ ] Child Abuse / Neglect [ ] Grief / Fetal Loss [ ] Concerns Resources & Referrals: [ ] Counseling / Social Support [ ] Childcare Assistance [ ] Health Insurance [ ] Housing [ ] Food / Clothing [ ] Other COMMENTS / ADDITIONAL INFORMATION Public Health Nurse Referral Referral Date Phone Number Fax Number Email Address