DPH Central Intake Online Referral
Person Making Referral
Please enter information about the person making the Referral
1 .
Date of Referral
/
/
2 .
Referral Type
Choose One
Self - Mother
Self - Mother-To-Be
Self - Father
Self - Father-To-Be
Professional/Provider (E.G. Md, Nurse, Teacher)
Other (E.G. Neighbor, Friend)
3 .
First Name
4 .
Last Name
5 .
Middle
6 .
Address 1
7 .
Address 2
8 .
Zip Code
9 .
City
10 .
State
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington Dc
West Virginia
Wisconsin
Wyoming
11 .
County
Choose One
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
Dekalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
Mcduffie
Mcintosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Unknown
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
12 .
Phone Type
Choose One
Home
Cell
Work
13 .
Phone Number
-
-
14 .
Fax Numnber
15 .
Email
16 .
Referral Source
Choose One
Children 1st
Babies Can'T Wait
Children'S Medical Services
Child Care Centers/Providers
Public Health Programs
Dfcs
Health Department / Public Health Facility
Hospital
Neonatal Intensive Care Unit
Private Physician'S Office
Therapist
Parent To Parent
School/School Based Health Clinic
Head Start / Early Head Start
Family Connection
First Steps
Parents As Teachers
Nurse Family Partnership
Healthy Families Georgia
Capta
Other Health Clinics
Other Home Visiting Programs
Other Community Services
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
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington Dc
West Virginia
Wisconsin
Wyoming
9 .
Mother`s County
Choose One
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
Dekalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
Mcduffie
Mcintosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Unknown
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
10 .
Mother`s Phone Type for Primary Contact Number
Choose One
Home
Work
Cell
11 .
Mother`s Primary Contact Number:
-
-
12 .
Mother`s Phone Type for Alternate Number
Choose One
Home
Cell
Work
Family/ Friend Phone
13 .
Mother`s Alternate Number
-
-
14 .
Mother`s Date of Birth
/
/
15 .
Mother`s Email
16 .
Best Time to Contact
Choose One
Morning
Noon
Afternoon
All Day
Evening
Day Or Evening
17 .
Mother`s Preferred Method of Contact
Choose One
Home Phone
Cell Phone
Work Phone
Family/ Friend Phone
Email
Text
Letter
18 .
Primary Language (select one)
Choose One
English
Spanish
Nepali
Burmese
Somali
Kurdistan
Chinese Languages
French
German
Italian
Japanese
Korean
Polish
Philippine Languages
Farsi
Amharic
Russian
Arabic
Vietnamese
Sudanese
Unknown
Other
19 .
Needs Interpretation Services:
Choose One
Yes
No
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
Choose One
Male
Female
25 .
Child lives with
Choose One
Mother
Father
Guardian Parent
Foster Parent
26 .
Child`s Address
27 .
Child`s Address 2 (Apt)
28 .
Child`s City
29 .
Child`s State
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington Dc
West Virginia
Wisconsin
Wyoming
30 .
Child`s Zip Code
31 .
Child`s County
Choose One
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
Dekalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
Mcduffie
Mcintosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Unknown
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
32 .
Emergency Contact Phone Type
Choose One
Home Phone
Cell Phone
Work Phone
Family/Friend Phone
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
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington Dc
West Virginia
Wisconsin
Wyoming
42 .
Father`s County
Choose One
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
Decatur
Dekalb
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
Mcduffie
Mcintosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Unknown
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
43 .
Father`s Phone Type for Primary Contact Number
Choose One
Home Phone
Cell Phone
Work Phone
Family/Friend Phone
44 .
Father`s Primary Contact Number
-
-
45 .
Father`s Phone Type for Alternate Number
Choose One
Home Phone
Cell Phone
Work Phone
Family/Friend Phone
46 .
Father`s Alternate Number
-
-
47 .
Father`s Date of Birth
/
/
48 .
Father`s Email Address
49 .
Best Time To Contact
Choose One
Morning
Noon
Afternoon
All Day
Evening
Day Or Evening
50 .
Father`s Preferred Method of Contact
Choose One
Home Phone
Cell Phone
Work Phone
Family/Friend Phone
Email
Text
Letter
51 .
Primary Language (select one)
Choose One
English
Spanish
Nepali
Burmese
Somali
Kurdistan
Chinese Languages
French
German
Italian
Japanese
Korean
Polish
Philippine Languages
Farshi
Amharic
Russian
Arabic
Vietnamese
Sudanese
Unknown
Other
52 .
Needs Interpretation Services
Choose One
Yes
No
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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