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Prenatal and family home visiting program referral form

This is a referral form to Southeast Public Health’s prenatal and family home visiting program.

The content on this form is provided in English. However, services related to the Healthy Babies Healthy Children program are available in French.

If you require assistance or resources in French, we can provide translation services to support your needs. Please email us at:

Hasting and Prince Edward county area: fax1@southeastph.ca
Kingston, Frontenac and Lennox & Addington area: HBHC.intake@southeastph.ca
Leeds, Grenville, Lanark area: hbhc.lgl@southeastph.ca

Question Title

* I am:

Filling this form out for myself

A care provider referring my client to the program

Question Title

* What is the reason for the referral? Please check all that apply.

Client is looking for support with challenging life situations, such as being underhoused, relationship difficulties, or financial hardships.

Client is looking for support with parenting, supporting their child’s growth and development, and building a healthy relationship with their child

Client is seeking added support to enhance well-being while managing physical or mental health concerns that are making pregnancy or parenting more challenging

Client has limited supports and is looking to build their support network

Client is a newcomer to Canada looking for additional parenting support

Other (please specify)

Question Title

* Client consents to being contacted by a public health nurse
Note: only clients that provide their consent will be contacted

Yes

Collection of personal health information
Personal health information collected on this form is kept confidential and used to monitor local data, plan and provide local programs and services, case management, program administration, and program evaluation. You may withdraw your consent to provide additional health information at any time. Any questions about the collection and use of this information or for more information about our privacy practices, contact our Privacy Officer, at privacy.officer@southeastph.ca or call 1-800-660-5853.  Please see our Privacy Statement for more information.

Prenatal and family home visiting program referral form

Question Title

* I am:

Question Title

* What is the reason for the referral? Please check all that apply.

Question Title

* Client consents to being contacted by a public health nurse Note: only clients that provide their consent will be contacted

* Client consents to being contacted by a public health nurse
Note: only clients that provide their consent will be contacted