M2B

MIECHV REFERRALS TRACKING & FOLLOW-UP – INDEX PARENT

Please complete this form with Referral and/or Service Dates as updates occur and enter in THEO (EHS/HFA) or send to State (NFP)

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon	Nurse-Family Partnership

Parent ID #:

Name of Index Parent:

To meet Tobacco Cessation Referral Measure: Client must receive a Referral for Tobacco Cessation Counseling or Services within 3 months of Enrollment in MIECHV. Only ONE Referral is required for MIECHV; the service does not have to be started or received.	Recommended referrals include those made for tobacco cessation counseling or services. These referrals may include:	tobacco quit line,	primary care provider,	other tobacco cessation programs.

TYPE	REFERRAL Date Referred to Service	FOLLOW-UP Date Service Started/Received
Tobacco Cessation	/ / 20	N/A

To meet Depression Referral Measure: Client must receive a Referral AND at least one Service. Only ONE Referral and ONE Receipt of Service is required for MIECHV. Recommended referral services include: Internal referral to self or other staff member trained in Mothers and Babies intervention Internal referral to self or other staff member trained in Mental Health Intervention (for NFP programs) Licensed or licensed-eligible mental health provider (LMHC, LCSW, or LMFT) using cognitive behavioral therapy or another evidence-based treatment Medication therapy from a primary care provider, psychiatrist, or women’s health provider

TYPE	REFERRAL Date Referred to Service	FOLLOW-UP Date Service Started/Received
Depression	/ / 20	/ / 20