Required fields are marked with asterisks (*)

Healthy Babies Healthy Children program referral form

Healthy Babies Healthy Children (HBHC) is a free, voluntary program for expectant parents and families with children from birth up to transition to school.

Who can refer?

HBHC referrals can be made as a self-referral or a professional referral from a healthcare or service provider.

Eligibility:

expecting a baby; or
parenting a child from birth up to transition to school age; and
living in Huron or Perth county (area served by Huron Perth Public Health)

Referral source

Self-referral

Healthcare provider

Service provider

Other

If not a self-referral, name of person making referral

Service Organization and Contact information

Client information

First name:

Last name:

Date of birth:

Phone number:

Email address:

Street address:

Town/Municipality:

Postal code:

Preferred method of contact (public health nurse will contact you/client after receiving referral):

Phone

Text

Referral type

Prenatal (expecting a baby)

Postpartum (baby is newborn to 6 weeks old)

Early identification (child is 7 weeks to 6 years old)

Reason for referral to HBHC program

Primary care provider (family doctor or nurse practitioner) name:

Primary care provider phone number:

Other services you/client are involved with:

Child and Parent Resource Institute

Children's Aid Society

Huron Perth Centre

Ontario Disability Support Program

Ontario Works

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Other (e.g. medical specialist, social worker/counsellor)

Not applicable

How did you/client find out about the home visiting program?

Healthy Babies Healthy Children program pamphlet or poster

Huron Perth Public Health website

Primary care provider

Hospital

OBGYN or midwife

EarlyON Child and Family Centre

Calling All Three Year Olds (CATYO)

Friend or family member

By checking this box, I acknowledge that the information provided in this form is correct. I understand that I/client will be contacted by a Public Health Nurse.

Yes

Personal or personal health information on this form is collected under the authority of the Health Protection and Promotion Act and applicable privacy legislation. This information will be used for the delivery of public health programs and services and may be used for evaluation or statistical purposes. Any questions about the collection of this information should be directed to the Privacy Officer, Huron Perth Public Health, 1-888-221-2133 or email privacy@hpph.ca.

Forms

Healthy Babies Healthy Children program referral form

Who can refer?

Client information