Referrals

What are referrals?

Healthy Start referrals are voluntary screening tool that allows our Healthy Start Coalition to reach out to additional moms, dads, and babies that may be at risk for poor birth or developmental outcomes.

Referral Form

Click the file below to download our referral form.

DOWNLOAD FILE

Who can fill out a referral?

Any member of the community who has obtained consent from the person being referred can fill out the referral form. This includes but is not limited to:

Pediatric offices
OB/GYNs
The Department of Children and Families (DCF)
Social workers or mental health providers

Escambia Connect Referral Form 2023 (1).jpg

How should I fill out the referral form?

All required information is highlighted. Please make sure to include all information or we will not be able to properly process the referral.

Special Cases:

For infants: the infant's name, DOB, gender, address, and phone number should be included under "Client Information." And mother's information should be included in the "Parent/Guardian" section.
If the child is not in the care of the mother, and you are referring the infant: the infant's name, DOB, gender, address, and phone number should be included under "Client Information." And guardian's information should be included in the "Parent/Guardian" section.
If the child is not in the care of the mother, and you are referring the mother: the patient being referred would be marked as "mother without infant who is less than 18 months postpartum," and mother's information would be included in the client information.
For incarcerated people: we are not able to contact anyone who is currently incarcerated.

How do I send in a referral?

Referrals should be faxed to (850) 696-2551. If you are unable to fax, please send the email to referrals@healthystart.info.