DPH Central Intake Online Referral 
  Person Making Referral
Please enter information about the person making the Referral
1 . Date of Referral//
2 . Referral Type
3 . First Name
4 . Last Name
5 . Middle
6 . Address 1
7 . Address 2
8 . Zip Code
9 . City
10 . State
11 . County
12 . Phone Type
13 . Phone Number--
14 . Fax Numnber
15 . Email
16 . Referral Source
17 . Referral Agency
  Parent/Child Information
1 . Mother`s First Name
2 . Mother`s Last Name
3 . Mother`s Middle Name
4 . Mother`s Address 1
5 . Mother`s Address2
6 . Mother`s City
7 . Mother`s Zip Code
8 . Mother`s State
9 . Mother`s County
10 . Mother`s Phone Type for Primary Contact Number
11 . Mother`s Primary Contact Number:--
12 . Mother`s Phone Type for Alternate Number
13 . Mother`s Alternate Number--
14 . Mother`s Date of Birth//
15 . Mother`s Email
16 . Best Time to Contact
17 . Mother`s Preferred Method of Contact
18 . Primary Language (select one)
19 . Needs Interpretation Services:
20 . Child`s First Name
21 . Child`s Last Name
22 . Child`s Middle Name
23 . Child`s Date of Birth//
24 . Child`s Gender
25 . Child lives with
26 . Child`s Address
27 . Child`s Address 2 (Apt)
28 . Child`s City
29 . Child`s State
30 . Child`s Zip Code
31 . Child`s County
32 . Emergency Contact Phone Type
33 . Emergency Contact Number--
34 . Father`s First Name
35 . Father`s Last Name
36 . Father`s Middle Name
37 . Father`s Address 1
38 . Father`s Address 2
39 . Father`s City
40 . Father`s Zip Code
41 . Father`s State
42 . Father`s County
43 . Father`s Phone Type for Primary Contact Number
44 . Father`s Primary Contact Number--
45 . Father`s Phone Type for Alternate Number
46 . Father`s Alternate Number--
47 . Father`s Date of Birth//
48 . Father`s Email Address
49 . Best Time To Contact
50 . Father`s Preferred Method of Contact
51 . Primary Language (select one)
52 . Needs Interpretation Services
  Referral Information
1 . Reason for Submitting the Referral
       Conditions Identified at Birth
       Socio-Environmental Conditions Present in the Family
       Infectious and Parasitic Diseases
       Mental Disorders
       Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders
       Diseases of the Blood and Blood-Forming Organs
       Diseases of the Nervous System and Sense Organs
       Serious Problems or Abnormalities of the Body Systems
       Conditions Originating in the Perinatal Period
       Symptoms, Signs and Ill-Defined Conditions
       Injury and Poisoning
       Other Significant Conditions
2 . Comments
SendSS System Message:
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SendSS System Message:
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