First 5 First Steps: Referral Form
Please fax referrals to the region where the family resides.
See back of this form for regional fax numbers and zip codes.
Please note: First 5 First Steps is a home visiting program that serves families who belong to one or more of the eligibility categories
listed below. First Steps accepts referrals for expectant parents. See back of this form for details.
Eligibility Category:
(check all that apply)
Low-income (<200% FPL)
Military: Child is dependent of active, reserve, guard, or veteran
Referral Date:
Referral sent:
Prenatally
Refugee/immigrant family (foreign born parent)
Pregnant teen (age 13-21)
Postpartum (up to 1 week)
Referring Agency:
Referrer’s Name:
Referrer’s Phone:
Referrer’s Fax:
If postpartum, child’s DOB:
Referrer’s Email:
Mother’s Name:
Primary
Language:
DOB:
Ethnicity:
Mother’s Address:
City:
Mother’s Primary Phone:
Mother’s Alternate Phone:
Marital Status:
Married
Single
Separated
Divorced
Estimated Date of Delivery:
Health Coverage:
Private
Zip Code:
Widowed
Mother’s first baby:
Tri-Care
Medi-Cal
None
Yes
No
Date Prenatal Care Began:
Reason for Referral:
Consent:
I hereby authorize ____________________________________________________________ (Referring Agency) to submit my
referral for services to the First Steps program. The information is required for the purpose of determining eligibility for the First Steps
program and is limited to the following information: First Steps Referral Form; update on status of referral; client acceptance of
services. I understand that my authorization will remain effective for one year from the date of this referral, and that the information will
be handled confidentially in compliance with all applicable local, state and federal laws.
Autorizo a ___________________________________( Agencia que refiere) a presentar mi referencia para servicios del programa
First Steps. La información se requiere para determinar elegibilidad para el programa First Steps y está limitada a: esta forma de
referencia , y información sobre la actualización del estatus de la referencia y aceptación de los servicios por parte del cliente
Entiendo que mi autorización permanecerá efectiva por un año desde la fecha de esta referencia , y que la información se manejará
confidencialmente en cumplimiento con las leyes aplicables estatales y federales.
____________________________________________ (client signature/ firma de cliente)
☐ Verbal
Recipient will confirm receipt of referral within 2 business days and provide a status update within 60 days.
☐ Check here if you do not wish to receive a status update on this referral.
BELOW TO BE COMPLETED BY RECIPIENT
First Steps Eligibility Screening
Client Screened
Client Declined Screening
Eligible for First Steps
Unable to Contact Client
Ineligible for First Steps
First Steps Services (for eligible clients only)
Accepted First Steps Services
Declined First Steps Services
Referral Follow Up Tracking
Date Receipt Confirmed:
Date Status Update Sent:
The information contained in this facsimile message is legally privileged and confidential information intended only for the use of the individual or entity
named above. If the receiver of this message is not the intended, you are hereby notified that any dissemination, distribution or copying of this facsimile is
strictly prohibited. If you receive this facsimile in error, please notify the sender immediately.
SR
Jun2015
First 5 First Steps: Referral Form
Please fax referrals to the region where the family resides.
See back of this form for regional fax numbers and zip codes.
Referral Instructions
Fax the front side of this form to the region where the family lives. See the zip code list below.
Please ensure client has provided consent.
What Referred Families Can Expect
All families referred to First Steps will be contacted by phone to complete a New Baby Questionnaire (NBQ). The NBQ is a screening
tool used to determine initial eligibility for the program.
Program Information
First Steps is a home visiting program that accepts referrals for expectant parents. On a case-by-case basis, the program may consider
postpartum referrals only of infants who are less than one week old. Families must meet at least one of the following eligibility criteria:
 Low income families (<200% of the Federal Poverty Level)
 Refugee/immigrant families (at least one parent was born outside of the United States)
 Military families (child is dependent of active, reserve, guard or veteran)
 Teen parents (age 13-21)
First Steps serves families that do not qualify for other home visiting programs in San Diego County. Families who qualify for one of the
following programs should be referred to that program instead of First Steps.
 Nurse Family Partnership: First time mothers who are ≤28 weeks pregnant
 Maternal Child Health: High risk pregnancy
 New Parent Support Program: Active-duty service members and their dependents prenatally through ages 3 – 5 (depending
upon branch of service). Marine Corps serves through age 5
Central
Fax: 619.961.1025
Phone: 619.283.9624
x285
92101
92102
92103
92104
92105
92113
92114
92115
92116
92130
92131
92134
92136
92139
92140
92145
92161
92182
North Central
Fax: 619.961.1025
Phone: 619.283.9624
x285
92037
92093
92106
92107
92108
92109
92110
92111
92117
92119
92120
92121
92122
92123
92124
92126
East
Fax: 619.328.0638
Phone: 619.938.3239
91901
91905
91906
91916
91917
91931
91934
91935
91941
91942
91945
91948
91962
91963
91977
91978
91980
92019
92020
92021
92040
92071
North Coastal
Fax: 760.739.2835
Phone: 760.739.3261
92007
92008
92009
92010
92011
92014
92024
92054
92055
92056
92057
92058
92067
92075
92081
92083
92084
92091
92672
North Inland
Fax: 760.739.2835
Phone:
760.739.3261
92003
92004
92025
92026
92027
92028
92029
92036
92059
92060
92061
92064
92065
92066
92069
92070
92078
92082
92086
92096
92127
92128
92129
92259
92536
South
Fax: 619.336.8369
Phone:
619.336.8364
91902
91910
91911
91913
91914
91915
91932
91950
92118
92135
92154
92155
92173
The information contained in this facsimile message is legally privileged and confidential information intended only for the use of the individual or entity
named above. If the receiver of this message is not the intended, you are hereby notified that any dissemination, distribution or copying of this facsimile is
strictly prohibited. If you receive this facsimile in error, please notify the sender immediately.
SR
Jun2015