Vancouver/Richmond Fax to: 604-253

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PRENATAL REFERRAL FORM
‰ Healthiest Babies Possible Program (HBP)
‰ Youth Pregnancy & Parenting Program (YPPP) <22 years
OR
Vancouver/Richmond Fax to: 604-253-1925
Email: [email protected] / [email protected]
PHN: ____________________ PARIS ID:___________
Date of Referral:_______________________________
Last Name:____________________________________
Referrer’s Name/Role:__________________________
First Name: ____________________ Middle: _______
Referral Phone:_________________________________
DOB:_______________________ Age:____________
Address:_______________________________________
______________________________________________
Family Doctor:_________________________________
Delivering Doctor/Midwife:_______________________
Postal Code: ___________________
CHC:________
Clinic Address:_________________________________
Telephone: ____________________
ok to leave msg
Phone: _______________________________________
Cell: _________________________
ok to leave msg
Due Date: _______________
Weeks Gest:________
Email:________________________________________
Country of Origin:____________ Ethnicity:_________
Other contact person: ____________________________
Language:______________ English:
Fluent
Basic
MEDICAL / SOCIAL HISTORY
“How can we help (or support) you?”
PLEASE SPECIFY REASON FOR REFERRAL
BMI or weight gain concerns:_______________
Low income (Do you have enough for basics like rent and food?)
Adequate nutrition:_______________________
Social isolation (Do you have friends or family you can talk to?)
Mental health:___________________________
First Nations
Smoking:_______________________________
Recent immigrant (< 2yrs): _________________
Substance Use: __________________________
Single parent: ____________________________
Abuse:_________________________________
Not completed high school: _________________
Other: _________________________________
Age 22 or under*
*For YPPP, attach antenatal record, all blood work and ultrasound report
OFFICE USE ONLY
HBP #_______________ PARIS ID:____________ HBP Staff: ______________________________ Date: _________________
YPPP only: Telephone Contacts: ______________________________________________ EMR Appt booked:___________________
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