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MCO Referral - Healthy Blue MCO Referral - Show Me Healthy Kids (Home State Health)
Date Questionnaire Completed
* must provide value
Today M-D-Y (Please click the Today button)
Home visiting is a free and voluntary service for parents who are pregnant or have a young baby or child not older than 5 years old. Home visiting agencies that are part of this referral system serve families in Southeast Missouri. If you are not located in our service area, you will be redirected to your area's referral system.
Please fill out the information below to have someone contact you about home visiting. Your answers will help us find an agency that is the best fit.
First, we want to ask you a little bit about the primary caregiver, how best to reach them, and current resources available to the family.
Who will be receiving these services?
* must provide value
Biological Mother
Biological Father
Other Caregiver
(This will be the Primary Caregiver throughout the entirety of the case)
If recipient of services is "Other" please specify here.
Parent/Guardian's First Name?
* must provide value
Parent/Guardian's Last Name?
* must provide value
Parent/Guardian's Street Address
City:
* must provide value
What County and State does the parent/guardian live in?
* must provide value
Adair MO Andrew MO Atchison MO Audrain MO Barry MO Barton MO Bates MO Benton MO Bollinger MO Boone MO Buchanan MO Butler MO Caldwell MO Callaway MO Camden MO Cape Girardeau MO Carroll MO Carter MO Cass MO Cedar MO Chariton MO Christian MO Clark MO Clay MO Clinton MO Cole MO Cooper MO Crawford MO Dade MO Dallas MO Daviess MO DeKalb MO Douglas KS Dent MO Douglas MO Dunklin MO Franklin KS Franklin MO Gasconade MO Gentry MO Greene MO Grundy MO Harrison MO Henry MO Hickory MO Holt MO Howard MO Howell MO Iron MO Jackson MO Jasper MO Jefferson MO Johnson KS Johnson MO Knox MO Laclede MO Lafayette MO Lawrence MO Leavenworth KS Lewis MO Lincoln MO Linn MO Livingston MO Macon MO Madison MO Maries MO Marion MO McDonald MO Mercer MO Miami KS Miller MO Mississippi MO Moniteau MO Monroe MO Montgomery MO Morgan MO New Madrid MO Newton MO Nodaway MO Oregon MO Osage MO Ozark MO Pemiscot MO Perry MO Pettis MO Phelps MO Pike MO Platte MO Polk MO Pulaski MO Putnam MO Ralls MO Randolph MO Ray MO Reynolds MO Ripley MO Saline MO Schuyler MO Scotland MO Scott MO Shannon MO Shelby MO St. Charles MO St. Clair MO St. Francois MO St. Louis County MO St. Louis City MO Ste. Genevieve MO Stoddard MO Stone MO Sullivan MO Taney MO Texas MO Vernon MO Warren MO Washington MO Wayne MO Webster MO Worth MO Wright MO Wyandotte KS None of the above (connect to someone else) Unsure
Zip Code of Family
* must provide value
(I)
Please complete the form and someone will contact you to suggest resources in your area.
The county you selected is outside of our referral system's service area; however there is another home visiting collective and referral system that serves that area: Promise 1000 - Home Visiting Collective. Click here to be connected to the Promise 1000 website: www.promise1000.org  and select "Start Referral".Â
The county you selected is outside of our referral system's service area; however there is another home visiting collective and referral system that serves that area: Brighter Beginnings. Click here to be connected to the Brighter Beginnings website: www.brighterbeginnings.org and select "Start Referral".Â
The county you selected is outside of our referral system's service area; however there is another home visiting collective and referral system in that area: Family Focused Network. Click here to be connected to their referral system: Family Focused Network - Home Visiting Referral
The county you selected is outside of our referral system's service area; however there is another home visiting collective and referral system that serves that area:Â Generate Health - Home Visiting Collaborative.
Click here to be connected to their referral system: Generate Health - Home Visiting Referral Form
Parent/Guardian's Home Phone
* must provide value
Parent/Guardian's Cell Phone (If the same as the home phone, leave blank)
Message Phone/Relative Phone (If the same as the home phone, leave blank)
(Only if parental phone # not available)
No Email Available
(I)
Primary Parent/Guardian's Date of Birth
Today M-D-Y (*must provide value)
Primary Parent's Age (In Years)
View equation (I) (Automatically populates with DOB)
Family's Preferred Spoken Language
* must provide value
Amharic Arabic Arkanese Assyrian Bosnian Buganda Burmese Chinese Dari Dinka Dzongkha English Falam Farsi French Fur German Hahka Hindi Japanese Kaba Kayah (Karenni) Kinyarwanda Kirundi Krahn Kunama Kurdi Kurdish Lai Lautu Maay Maay/MaiMai Malay Mbai Mixteco Nepali Pashto Po Karen Punjabi Russian Sango Senthang Sgaw Karen Shan Somali Spanish Swahili Tedim Thai Tigre Tigrinya Turkish Urdu Vietnamese Zaghawa Zokhua Zotung Other
Other Language(s) Spoken
* must provide value
Primary Parent/Guardian's Ethnicity
* must provide value
Hispanic, Latino or Spanish Origin Non-Hispanic
Primary Parent/Guardian's Race
* must provide value
African American or Black American Indian or Indigenous American or Alaska Native Asian Caucasian or White Middle Eastern or North African Multiracial, Biracial, or Multiple Ethnicities Native Hawaiian or Other Pacific Islander Prefer to Self-Identify/Other Declined to answer
If "Race" is other, please specify:
* must provide value
Is the primary caregiver enrolled in any educational or training programs?
Middle School High School or GED program College Professional/Vocational Training Not Enrolled
(I)
What is the mother's/primary caregivers highest level of education?
* must provide value
Did Not Complete High School
High School Diploma/GED
Some College
Technical Training or Certification
Associate's Degree
Bachelor's Degree
Master's Degree
Ph.D.
Unknown
(I)
Is the primary parent currently employed?
* must provide value
Employed Part Time (less than 30 hours per week) Employed Full Time (30+ hours per week) Unemployed Not Employed due to Disability Not Employed due to pregnancy/maternity leave Retired
(I)
Are any other adults in the parent's home currently employed?
* must provide value
Yes
No
(I)
What is the parent's current marital status?
* must provide value
Single (Never Married)
Married
Separated
Divorced
Unmarried Partners
Widowed
(I)
Is the parent currently a single parent?
* must provide value
Yes
No
(I)
Do you know the amount of money you, and the family living with you, make in one year?
* must provide value
Yes
No
How much money do you, and family living with you, make in one year? - numbers only, no commas please!
* must provide value
Estimated yearly household income of ALL household members-Include employment, child support, TANF or financial assistance, SSI/SSDI, and all other legal sources of income.
How many people in the parent's family are living in the home?
* must provide value
(kids, spouse, other family living together, etc...)
Federal Poverty Level Calculation: 185% or Below
View equation Federal Poverty Level Calculation: 195% or Below
View equation Does the parent receive any public support (WIC, TANF, or something else)?
* must provide value
(Please check all that apply)
Would biological mother say that alcohol or other drugs are creating a problem now or have in the past?
Yes
No
Unknown
Is the Primary Caregiver in Foster Care?
Yes
No
(Includes youth (< 23 years of age) currently in the care, custody and control of the State and placed in an alternative setting such as a foster home, relative/kinship home, independent living arrangement, group foster home or residential facility - ANY legal status)
If in foster care, please provide the alternative care case number from Children's Division:
(This number is not the DCN and the youth can get it from their case worker)
Foster Care Legal Status:
Legal Status 1 (Currently in Foster Care)
Legal Status 5 (Adoption Subsidy)
Legal Status 9 (Guardianship Subsidy)
Post Legal Status 1 (P-LS1)
(If received from MCO referral)
Next, we want to ask you a little bit about the mothers current pregnancy, or if the baby is born, about the parent's youngest child.
Is this the FIRST baby or child for the parent?
* must provide value
Yes
No
Unknown
Currently pregnant?
* must provide value
Yes
No
Today M-D-Y (If known)
How far along is the pregnancy in weeks?
* must provide value
(If unknown, please give your best guess)
Age of youngest child in months
* must provide value
Prenatal (Pregnant) 0-1 month old 2 months old 3 months old 4 months old 5 months old 6 months old 7 months old 8 months old 9 months old 10 months old 11 months old 12 months old 13 months old 14 months old 15 months old 16 months old 17 months old 18 months old 19 months old (1yr, 7mo) 20 months old (1yr, 8mo) 21 months (1yr, 9mo) 22 months (1yr, 10mo) 23 months (1yr, 11mo) 2 years 2yrs, 1mo 2yrs, 2mo 2yrs, 3mo 2yrs, 4mo 2yrs, 5mo 2yrs, 6mo 2yrs, 7mo 2yrs, 8mo 2yrs, 9mo 2yrs, 10mo 2yrs, 11mo 3yrs 3-5 years
First name of the youngest child? (If born)
(Leave blank if pregnant and no other children)
Youngest child's date of birth (If born)
Today M-D-Y (If pregnant still leave blank)
View equation (Autocalculated) (I)
How many other/additional children does the parent have?
* must provide value
(I) (Not including the youngest child you've already told us about)
Has a Doctor, Health Provider, Teacher or School Official Ever Told the PCG That Any Child in the Household Had a Developmental Delay or Disability?
Yes
No
(I)
Type of Housing
* must provide value
Owns or shares own home or apartment (on the lease) Rents or shares own home or apartment (on the lease) Lives in Public Housing Shared housing/Lives with significant other (not on lease) Lives with Parent or Family Member (not on lease) Sharing Housing (homeless, lives with friends, etc. and not on lease) Transitional or Supportive Housing Some Other Arrangement (not homeless) Homeless and living in an Emergency or Transition Shelter Homeless - Some Other Arrangement (including living on the streets, etc.) Other
(I)
Has Anyone in the Household Served in the Military?
Yes
No
Has parent/guardian received previous Home Visiting services?
Yes
No
Unknown
Do you have a preferred home visiting agency?
Yes
No
What home visiting agency is preferred?
Bloomfield - Parents as Teachers Bringing Families Together - Healthy Families America Building Blocks/Nurse Family Partnership of Southeast Missouri Couch R-I School District - Parents as Teachers Dexter - Parents as Teachers Good Shepherd - Healthy Families America Lutheran Family & Children's Services - Healthy Families America MBCH Children and Family Ministries - Nurturing Parenting Program New Madrid Family Resource Center - Healthy Families America Nurses for Newborns Puxico - Parents as Teachers Richland - Parents as Teachers Southern Reynolds R-II School District - Parents as Teachers Ste. Genevieve County RII School District - Parents as Teachers Twin Rivers R-10 School District - Parents as Teachers Whole Kids Outreach - Child Nursing Home Visiting Program Whole Kids Outreach - Healthy Families America
(can be used for external referrals)
Lastly, please provide us with some information on who is completing this referral for home visiting, so we can contact you as needed.
Who is filling out this referral form?
* must provide value
Mom (parent)
Dad (parent)
Other Caregiver
Medical Professional
Call Center Employee (including 211)
Home Visiting Agency or Home Visitor (External Referral/Self-Referral)
DSS - Children's Division/Family Support Division
Other Type of Home Visitor (not a self-referral)
Managed Care Company/Organization (MCO)
Managed Care Organization (MCO) - *OLD/HIDDEN
Other
I'm with an organization and referring someone else *HIDDEN/OLD
Please specify, other caregiver:
Please specify, your role/occupation:
Other person filling out form - relationship
What Children's Division Unit are you in?
Alternative Care Case Family Centered Services Case Investigation Prevention Services Newborn Crisis Assessment Other Unit
Which judicial circuit does the family reside in?
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First name of person filling out this questionnaire?
Last name of person filling out this questionnaire?
(Only utilized if have questions about the form)
Additional phone number for person filling out this questionnaire:
Email Address for person filling out this questionnaire:
How did you hear about us?
Billboard/Advertisement City Bus Advertisement Pamphlet/Handout Social Media Website Family/Friend Medical Provider Social Service Provider Other
If you wish to receive updates on the status of this referral, including which agency is assigned, please enter your email here.
Signatures & Uploads Section - HIDDEN
Signature of Caregiver verifying the information in the referral is accurate (If required by your agency)
Upload Documents (if needed)
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(I) (HFAs only)
By clicking "Submit" below, you give permission for all of the information entered into this referral form to be sent to Whole Kids Outreach staff and the local Home Visiting Agencies. If you are completing this form for the parent, you are agreeing that the parent gives permission to create and send the referral.
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