Name: Phone: Fax: E-mail: Date of Referral: Referral Source: (select as many as apply) Healthy Communities School 211 Hospital – Children’s Hospital Specialty Provider BIAC (i.e. OT, PT, speech) Hospital – Other Brochure Support Group Services Human Services Board of Community Transfer from another HCP county Education Services (BOCES) Individual Services Support Team Website – CDPHE CICP Medical Provider – Primary Website – LPHA CHP+ Medical Provider – Specialty Website – Other Community Center Boards Mental / Behavioral Health WIC Community Partner NICU Work Family Member Other Public Health Program Refused Family Voices Previous HCP Care Coordination Didn’t Ask Client Friend Other, ________ Public Health Department HCP Specialty Clinic RCCO/RAE Did the family refuse to complete the intake interview? No Yes [Talking Point: Only select “yes” if the family does not intend to continue with Care Coordination services.]
Date of Referral: Name: Phone: Fax: E-mail: Referral Source: (select as many as apply) 211 BIAC Brochure Board of Community Education Services (BOCES) CICP CHP+ Community Center Boards Community Partner Family Member Family Voices Friend HCP Specialty Clinic Healthy Communities Hospital – Children’s Hospital Hospital – Other Human Services Individual Services Support Team Medical Provider – Primary Medical Provider – Specialty Mental / Behavioral Health NICU Other Public Health Program Previous HCP Care Coordination Client Public Health Department RCCO/RAE School Specialty Provider (i.e. OT, PT, speech) Support Group Services Transfer from another HCP county Website – CDPHE Website – LPHA Website – Other WIC Work Refused Didn’t Ask Other, ________ Did the family refuse to complete the intake interview? [Talking Point: Only select “yes” if the family does not intend to continue with Care Coordination services.] Yes No
PF_HCP_Intake-Intvw-FY18_1.docx