HIV Care Referral Form
The HIV Care Referral Form is to be completed by agencies that provide services to women who are currently pregnant, post-partum, or infants born to an HIV-positive person. This form should also be completed if client need services while pregnant or after delivery.
Date of Referral:
/
/
Agency Name:
Agency Address:
Agency City:
Agency State:
Agency Zip Code:
Agency Phone Number:
Person Completing Form:
Person to Contact for Follow-up:
Reason(s) for Referral
Adherence Counseling
Family Planning
Newborn Care
Obstetric Care
Postpartum follow-up
Mental Health Services
Substance Abuse Treatment
Other
Patient Information
Name:
Address:
City:
State:
County:
Zip Code:
Home Phone:
Cell Phone:
Maternal History
Birth Mother Name (Last, First, M.I.)
:
Birth Mother DOB
/
/
Due Date/Delivery Date
/
/
Date confirmed HIV+
/
/
Patient started on ART
Prenatal Care:
Yes
No
Unknown
Weeks gestation when started
OB/GYN Provider:
Primary Care Provider:
Mental Health Concerns:
Yes
No
Unknown
Syphilis:
Yes
No
Unknown
If yes, enter date
/
/
Hepatitis:
Yes
No
Unknown
If yes, enter date
/
/
Paternal History
Birth Father Name (Last, First, M.I.):
Birth Father DOB
/
/
Currently enrolled in PrEP:
Yes
No
Unknown
Date began:
/
/
Newborn History
Newborn Name:
Newborn Date of Birth:
/
/
Hospital at Birth
Hospital
City:
State:
County:
Residence at Birth
City
County:
State:
Zip Code:
Pediatrician (If not yet determined, please check box)
Name
City:
State:
County:
Phone:
Additional Notes:
For any questions related to this form, please contact Crystal Fuller at Crystal.Fuller@dph.ga.gov
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