Maternal and Child Health Home Visiting Referral Form

This is a referral for home visiting services through the Maternal Child Health Division at the Ingham County Health Department. This form may be completed by prospective clients or by referring agencies. All services are voluntary, and staff use the information provided to best connect individuals with one of our home visiting programs. Once complete, the referral will be reviewed and assigned to a home visitor, who will contact the individual within three to five days.

Client Information

Client Address/Contact Information

Additional Contact Information


Client Medical Information

Client Current Status (check all that apply):

(Don’t include current pregnancy)

Client Health Care Provider Information

Insurance Information

Health Insurance Type (select all that apply)

Child Medical Information

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Associated Children Medical Information

First Name Last Name Date of Birth Gender Actions


Please explain circumstances, above risks, and any other risks or concerns.

Referral Document Upload(s)

- Files types are limited to: Images(png, jpg, gif), PDF and Word (docx, doc) files (File size limited to 5MB)

Program(s) Assignment

Program Program Status Home Visitor Date of Assignment Date of Enrollment Date of Closure Reason For Closure

Referral Status