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  • Public Health Nurse Referral

    Tacoma-Pierce County Health Department is committed to protecting the confidentiality of your medical information, and the law requires us to do so. Read the complete Notice of Privacy Practices.

    Which nursing service are you requesting (descriptions below)?
    Nurse-Family Partnership- Nurse home visiting designed for first-time moms less than 28 weeks pregnant at time of referral. This program follows baby until 2nd birthday.
    Maternity Support Services- Nurse home visiting for Medicaid eligible/enrolled moms, pregnant through 2 months of age.
    Maternal Outreach Team- Consult with an outreach worker—Robyn or Sharon—for assistance with health insurance, finding a doctor or other pregnancy support.
    Black Infant Health- Health Ministers meet with pregnant women and families, offering one-on-one contact and social support. They also link families with basic needs.
    Are you filling out the form for yourself or someone else?

    Complete this section only if you are referring someone other than yourself.

    Referrer Name
    The family knows I am making this referral.
    When the family is contacted, please contact me by:

    Mother’s Information

    Name
    MM slash DD slash YYYY
    Homeless?
    Address
    Address(Required)

    Pregnancy Information

    Pregnancy(Required)
    Trimester (if pregnant)(Required)
    MM slash DD slash YYYY
    When did you begin prenatal care?

    Complete this section only if you already delivered your baby.

    MM slash DD slash YYYY
    Delivery
    Baby's gender
    Feeding

    Other Information

    My medical insurance is:
    Select any of the following that apply to you.