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.

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 or faxed as well.

Child/Family Contact Information

Client's Name

PCP Address
Interpreter needed (optional)
Do you live in Clackamas County?

Referral Source

Name (optional)