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

Name(s)

Last Name(s)

Primary Care Provider (PCP) (optional)

Address (optional)

City (optional)

State (optional)

ZIP (optional)

What is the best way to contact you? (optional>

Date of Birth

Phone

Sex

Male

Female

Parent/Guardian (optional)

Relationship to the Child (optional)

Interpreter needed (optional)

Yes

What Language (optional)

Do you live in Clackamas County?

Yes

Reason for referral and other information?

Referral Source

Name(s) (optional)

Last Name(s) (optional)

Facility (optional)

Phone (optional)

Email (optional)

Public Health Nursing (PHN) Referral Form

Child/Family Contact Information

Client's Name

Referral Source

SHORTCUTS

ELECTED OFFICIALS

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