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Public Health Nursing (PHN) Referral Form

To protect the health of our public and our employees during the current COVID-19 pandemic, Clackamas County has closed this office to the public, effective until at least April 20.

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