Community to Home C2H Referral Form

The Community to Home Program serves families of at-risk children or children already diagnosed with a special healthcare need who live in the following counties: Adams, Blair, Franklin, Fulton, Huntingdon, Juniata, Mifflin, Perry, Carbon, Columbia, Monroe, Pike, Schuylkill, Susquehanna, Wayne, and Wyoming.

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* 1. Referral Date

Date of Referral

Date

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* 2. Referral Provider Information

Provider First and Last Name:

Phone Number:

Email Address:

Title:

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* 3. CHILD (1) INFORMATION

FIRST NAME

LAST NAME

DATE OF BIRTH

GENDER

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* 4. CHILD (2) INFORMATION

FIRST NAME

LAST NAME

DATE OF BIRTH

GENDER

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* 5. PRIMARY CAREGIVER INFORMATION

First Name:

Last Name:

Date of Birth:

Primary Language:

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* 6. Contact Information

Phone:

Home Address:

County:

Email:

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* 7. Reason For Referral: Check all that apply.

There are concerns for the child’s physical, social, or emotional state

Child with SHCN-sibling conflict

Assistance with child transitioning to adult practice

Linkages to community resources

The client requested to be referred to CTH or community programs

The client is transferring to another clinic and needs services

Poor medical appointment attendance (e.g. no shows)

Concerns for the family safety or environment

Caregiver-child conflict

Language barrier

Caregiver with unmanaged physical or mental health needs

Family needs health education

Other (please specify)

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* 8. Is the child(ren) at risk or recently diagnosed with a special healthcare need? Is there anything else you would like to add?

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* 9. Is the family aware that this referral is being made?

Yes

If No (please specify)