HealthyStart Referral Form – Northshore Youth and Family Services

Referral Information Form

Northshore Youth & Family Services Healthy Start (HS) is an evidence-based Parents as Teachers (PAT) affiliate, helping low-income parents and guardians support their child’s overall health and early child development. Our program provides free services to young parents up to age 24 who are pregnant and/or with their first child. We provide 2 home visits per month, group activities, regular screenings, and assessments. We serve those living in North King County and South Snohomish County, including Woodinville, Bothell, and Northgate.

Person Referring

Date

Fax Number

Email Address

Phone Number

Agency

Primary Parent/Guardian Information

Last Name

First Name

Date of Birth

Address

City

Zip

Phone

Home Phone Cell Phone

Ok to leave message?

Yes No

Aware of Healthy Start Referral?

Yes No

Gender Identity (Select all that apply)

Male

Female

Transgender/GNC

Preferred Language(s) (Select all that apply)

English

Spanish

Other (below):

Race/Ethnicity (Specify)

Pregnant?

Yes No

If Yes, Due Date:

Current Sources of Support (Select all that apply)

WIC PH DSHS TANF Medical Coupon Food Stamps Family Other

Issues of Concern (Select all that apply)

Depression Substance Use Domestic Violence/IPV CPS Disabilities Homelessnes

Other:

Child Information (Age 0 to 3)

First and Last Name

Gender

M F TGNC

Date of Birth

First and Last Name

Gender

M F TGNC

Date of Birth

First and Last Name

Gender

M F TGNC

Date of Birth

First and Last Name

Gender

M F TGNC

Date of Birth

Comments / Questions

Referral Information Form

Primary Parent/Guardian Information

Child Information (Age 0 to 3)

Thank you for providing us with the opportunity to serve this family