Alert
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Public Health Nursing (PHN) Referral Form

Visit our Closures page for the latest information about office closures.
We also encourage you to call before visiting any county office.
Office Closures

Nurse Home Visiting services are being offered virtually. New clients are being accepted.

Email homevisitingnurse@clackamas.us
Fax 503-655-8388

Please fill out all applicable fields and click submit. Or you can print the form and fax it to 503-655-8388.  If you have supporting documents or chart notes they can be emailed to homevisitingnurse@clackamas.us or faxed as well.

Child/Family Contact Information

Client's Name
Sex
Interpreter needed (optional)
Address
Type of insurance (optional)
Phone options (optional)
Phone options (optional)

Reason for Referral

Infant/Child Issues (optional)
Child/family has also been referred to (optional)

Referral Source

Name (optional)
PCP Address