Will County Health Department

HEALTHY FAMILIES ILLINOIS REFERRAL FORM

FAX SHEET
Fax form to Jill Garbaliauskas at 815-727-8677

SECTION 1: CLIENT INFORMATION (Please print)

CLIENT CONTACT
INFORMATION

Client Name: ______________________________________ Date of Birth: ____/____/______

Street Address/Town: ___________________________________________________________
Phone Number (Area Code) + Number: (_____)___________ Alternate phone: (_____)__________
When Should We Call?
9 am11 am
11 am1 pm
1 pm4 pm

Clients Due Date: ___________________

First Pregnancy: Yes No
Marital Status: S M W D Sep
Race/Ethnicity: African American
Caucasian
Income: ________________

Language Preference (Check one)

English
Spanish
Other (specify) ________________________________________

Hispanic

Other: __________________

SECTION 2: SCHOOL PROFESSIONAL (Complete the following)

Please check off the following that apply to the client:
History of depression/anxiety or any other mental health concerns
Past/current alcohol abuse
Past/current substance use/abuse
History of violence
Late prenatal care (13 weeks or later)
Abortion/Adoption sought or attempted during this pregnancy
MOB is unemployed or underemployed
Family has trouble paying for basic living expenses (WIC, Link, TANF)
FOB is unemployed or underemployed
Family has unstable housing
MOB is isolated (no phone, no transportation)
Support system is inadequate (no friends or family available)
Relationship or family problems
MOB has less than high school diploma or GED education
Other issue(s) which place family at risk for child maltreatment:
Specify: ___________________________________________________________

SECTION 3: HFI STAFF (Follow-up notes)

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