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Children 1st DIRECTIONS: Please complete form on every (Georgia North Central Health District)

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Referral Source: ___________ Date Received: ____________
DIRECTIONS: Please complete form on every child, birth to
age 5, having any of the conditions listed on 1st or 2nd page.
Check or ll in as much information as possible. Send form to
local Children 1st Coordinator.
Child: ________________________________________________________
Last Name First MI
Date of Birth: ______________________ Birth weight: __________________
Sex: Male Female Unknown Gestational Age: ______________
Select race: (Mark all that apply)
White Black or African American
Asian American Indian or Alaska Native
Unknown Hawaiian/ Other Pacic Islander
Latino/Hispanic: Yes No Unknown
Hospital: ______________________ Discharge Date: _________________
Transfer Hospital: _____________________ Discharge Date: ___________
Type of Insurance:
Child’s Insurance #: (if known) _____________________________________
Mother: ______________________________________________________
Last Name First MI Maiden
Age: ____________________________ Date of Birth: _________________
Education: (last grade completed)
Marital Status: M NM SEP D W
Live in Partner: Yes No
Prenatal Care: 1st 2nd 3rd None
Parity G:____ P:____ Pre-Term:____ AB: Elective/Spontaneous ____ /____
Parent’s Medicaid #: _____________________________________________
SECTION A CHILD AND FAMILY INFORMATION
CHILD’S INFORMATION MOTHER’S INFORMATION
FATHER’S INFORMATION
______________________________________________________________
Last Name First MI
GUARDIAN/FOSTER CARE REFERRALS
______________________________________________________________
Guardian/Foster Parent Last Name First Phone Number
______________________________________________________________
DFCS Case Worker Last Name First Phone Number Fax Number
LANGUAGE NEEDS
Primary Language:___________ Translator/Interpreter Needed: Y N
Children 1st
Screening and Referral Form
______________________________________________________________
Name
______________________________________________________________
Street or Route
______________________________________________________________
City State Zip
______________________________________________________________
Phone Fax
CHILD’S PRIMARY MEDICAL/HEALTH CARE PROVIDER
CONTACT INFORMATION
Child Lives with: Mother Father Guardian Foster Parent
Child’s Address: ________________________________________________
Street /Route Apt Complex # / Mobile Hm Park#
________________________________________________
City County Zip
Phone #: __________________ Emergency Contact #: _________________
Caregiver email address: __________________________________________
SECTION B HOSPITAL INFORMATION
Newborn Hearing Screening: Not Screened Family Refused Screening
Inpatient: Date: ____/____/____ Left: Pass Refer Right: Pass Refer AOAE AABR Other
Outpatient: Date: ____/____/____ Left: Pass Refer Right: Pass Refer AOAE AABR Other
Equipment:
Vaccines Given During Hospital Stay:
Hepatitis B Vaccine: (date) _______
HBIG: (date) ___________________
Newborn Bloodspot Metabolic Screening: Not Screened Family Refused Screening
Conditions Identied at Birth
655.4 Suspected damage to fetus (Mother Smoked and/or
Drank, > 7 drinks/week, during Pregnancy)
765.16-765.18 Disorders r/t other preterm infants <2500 Grams
(5 lbs. 8 oz.) and > 1500 Grams
V23.7 Insufcient Prenatal Care (Little or no prenatal care)
V23.83-V23.84 Young Prima-/Multi-gravida (Maternal Age <18 years)
V62.3 Education Circumstances
(Maternal Education <12 Years)
SECTION C LEVEL 2 RISK CONDITIONS (3 OR MORE MUST BE PRESENT FOR ELIGIBILITY)
Child Abuse Prevention Treatment Act (CAPTA)
All CAPTA referrals are automatic referral (Child age birth to 3 years)
V60.81 Foster Care
995.5 Child Maltreatment Syndrome (Substantiated Case)
DFCS Referrals (no CAPTA)
V60.81 Foster Care (over age 3)
995.5 Child Maltreatment (Substantiated Case) (over age 3)
V61.05 Unsubstantiated or sibling of victim of substantiated case (birth to 5)
C1MD.1 Child under age 5 exhibiting physical or developmental delay
Socio-Environmental Conditions Present in the Family
V17.0 Psychiatric condition (Parental Mental Illness, Depression) V18.4 Mental Retardation (Parental Mental Retardation)
V60.0 Lack of Housing (Homelessness) V60.2 Inadequate Material Resources (Affecting Care of Child)
V61.05 Family disruption due to child in welfare custody V61.2 Parent-Child Problems (Questionable Mother/Child Attach)
V61.5 Multiparity - in Mother (<20 Years of age, >3 pregnancies) V62.0 Parental Unemployment
V62.5 Legal Circumstances (Parental Incarceration) V62.8 Other Psych. or Physical Stress, (History of Family Violence)
V16-V19 Family History of (Specify)_______________________ (Illness/disability affecting care of child)
C1SEC.1 Child Injuries (>3 in 1 Year) Requiring Medical Attention Specify:____________________________
SECTION D SIGNATURES
_________________________________________________________________________________________________________________________________
Name of Person Completing Form Agency Email Address Phone Date
Parent Signature (Encouraged but not required for referral) _______________________________________Parent Informed of Referral? Yes No
Form #3267 Page 1 of 2
Private
Tri-Care
None
Unknown
WellCare CMO
Amerigroup CMO
PeachState CMO
Medicaid PeachCare
Child’s Name: Mother’s Name:
SECTION E
(check all that apply) LEVEL 1 RISK CONDITIONS
(Medical/Biological Conditions Present in Child Indicating Referral to Public or Private Sector Care)
Infectious and Parasitic Diseases
042 HIV
090 Syphilis
Mental Disorders
299.00-299.01 Autistic disorder
315.3 Developmental speech or language disorder
315.9 Unspecied delay in development
C1MD.1 Suspected Developmental Delay
Endocrine, Nutritional & Metabolic Diseases, and Immunity Disorders
243 Congenital hypothyroidism
27X.X X Disturbances of amino-acid metabolism
(Metabolic disease)
Specify(code, diagnosis):___________________
Diseases of the Blood and Blood-Forming Organs
282.X Hereditary hemolytic anemias
Specify(code, diagnosis): __________________
Diseases of the Nervous System and Sense Organs
320 Meningitis, Bacterial
321 Meningitis, All Other
323.9 Encephalitis
343.1-343.9 Infantile cerebral palsy
345 Epilepsy/Seizure Disorder
348.3 Encephalopathy
356-359 Neuromuscular Disorder
362.26 or 362.27 Retinopathy of Prematurity (Grades 4 or 5)
369.XX Blindness and low vision
Specify (code, diagnosis):__________________
382.9 Unspecied otitis media – chronic
(recurrent or persistent)
389.XX Hearing Loss
Specify(code, diagnosis): __________________
C1DNS.1 Suspected Hearing Impairment
Serious Problems or Abnormalities of Body Systems
390 – 459 Heart/Circulatory System
460 – 519 Respiratory System
493 Asthma
520 – 579 Digestive System
580 – 629 Genito-Urinary System
710 – 739 Musculoskeletal System and Connective Tissue
740 – 759 Congenital anomalies
749 Cleft Palate/Lip
Specify Conditions for All Above (include Diagnosis Code):__________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
www.health.state.ga.us/programs/childrenrst (Rev 6/2012) Form #3267 Page 2 of 2
Conditions Originating in the Perinatal Period
760.71 Fetal Alcohol Syndrome
764.00 Light-for-dates infant without fetal malnutrition
unspecied (birth weight < 10% for gestational age)
764.9 Fetal Growth Retardation (Intrauterine Growth
Reduction-IUGR)
765.01-765.03 Disorders r/t extreme immaturity of infant
(BW < 999 gms)
765.14-765.15 Disorders r/t other preterm infants (BW 1000-1500 gms)
767.0 Subdural and cerebral hemorrhage due to birth trauma
768.5 Severe birth asphyxia (APGAR < 3 at 5 Minutes)
770.7 Chronic Respiratory Disease in perinatal period
(Broncho-pulmonary Dysplasia)
770.81 or 770.82 Primary apnea or other apnea in newborn
770.9 Unspec. Respir. Condition of fetus/newborn
(vent > 48hrs)
771.0 Congenital Rubella
771.1 Congenital cytomegalovirus infection (CMV)
771.2 Other congenital infection in perinatal period
(Herpes Simplex-congenital, Toxoplasmosis)
772.13 or 772.14 Intraventricular Hemorrhage (IVH), Grade III or IV
774.4 Perinatal jaundice d/t hepatocellular damage
(NB Hepatitis)
774.6   Neonatal jaundice (requiring exchange transfusion)
777.53 Stage III necrotizing enterocolitis in newborn
779.0 Convulsions in newborn
779.3 Feeding Problems in newborn
(severe reux/feeding tube)
779.5 Drug Withdrawal Syndrome in Newborn
779.7 Periventricular/Preventricular Leukomalacia (PVL)
C1COP.1 NICU Stay > 5 days
Symptoms, Signs and Ill-Dened Conditions
783.4 Failure to Thrive/Growth Deciency
(growth below 5th %)
796.4 Other abnormal clinical ndings
Specify(code, diagnosis):_____________________
Injury and Poisoning
959.01 Other and unspecied injury to head
984 .0-984.9 Toxic effect of lead and its compounds, including fumes
Lead Level > 20 µg/dl (Venous)
Specify:__________________
Lead Level > 10 <20 µg/dl (Venous)
Specify:_______________
C1INJ.1 Ototoxic medications including chemotherapy
Other Signicant Conditions
V02.6 Carrier/suspected carrier of viral hepatitis
(Hep. B in Mom)
V19.2 Family history of deafness or hearing loss
V61.41 or V61.42 Alcoholism or Substance Abuse in Family
(Maternal use of street, prescription or OTC drugs via
self-report, drug screen or court record)
237.70-237.79 Neurobromatosis
SECTION F REFERRAL CRITERIA LEGEND
Health Department Staff: Please see eligibility lists for Babies Can’t Wait, Children’s Medical Services, 1st Care, Universal Newborn
Hearing Screening, Genetics, and Lead Programs in order to appropriately refer children.
SECTION G COMMENTS
Has child received a recent developmental screening ?: Not screened Yes, screened by _____________________ (Please attach results)
Measure used: _____________________ Date screening completed__________________________ Scores _____________________________________
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Completed 21 April 2021

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