Referral Roadmap

Referral Forms:

Best practices ensure that a referral is made between agencies verses handing families a number to call.  Please use these referral forms to make a referral.  Please see talking points below to help deliver common messages about next steps:

• Developmental (0-3 years of age): Part C – Early Intervention- North Metro Referral – English;  Part C – Early Intervention – North Metro Referral – Spanish
• Developmental (3-5 years of age): Part B – Child Find Referral – English; Part B – Child Find Referral – Spanish
• Community Reach Center:
  • Behavioral/Mental Health Evaluation (0-7 years of age or Pregnancy-Related/Postpartum Depression/Anxiety): Referral and Release – English and Spanish
  • Autism Spectrum Disorder Program – this program has been discontinued
• Adams County General Referral Form (home visitation, oral health provider, or any other referral): English; Spanish
• SafeCare Home Visitation Program: SafeCare Referral Form
• Nurse Support Program: NSP Referral Form
• HIPPY Home Visitation Program: HIPPY Flyer and Enrollment Form- Spanish HIPPY Flyer and Enrollment Form- English
• Nurse Family Partnership Home Visitation Program: NFP_Cheat Sheet NFP_Referral Form

Talking Points and Program Contact Information:

The following documents contain all the information you need to introduce a referral, as well as the agency’s contact information, including where to send the referral.

• Behavioral/Mental Health (0-8 years of age or Pregnancy-Related/Postpartum Depression or Anxiety): Community Reach Center Talking Points
• Developmental (0-3 years of age): North Metro/Early Intervention Talking Points
• Developmental (3-5 years of age): Child Find Talking Points
• Oral Health Contact Information
• Home Visitation Programs (Prenatal-5 years of age): Nurse Family Partnership (NFP), Parents as Teachers (PAT), Home Instruction for Parents of Preschool Youngsters (HIPPY), SafeCare Colorado Talking Points, and Nurse Support Program
• Health Clinic Contact Information

Status Update Form:

Best practices ensure a referral feedback loop. Please use one of these Status Update Forms if your organization does not already have one.

• General Status Update Form

Release of Information Forms:

• Developmental (0-3 years of age): Part C – North Metro – English, Spanish
• Developmental (3-5 years of age): Part B – Child Find – School District 27J – English, Adams 12 – English & Spanish, Mapleton Public Schools (1) – English, Westminster Public Schools (50) – English, Westminster Public Schools (50) – Spanish
• Behavioral/Mental Health (0-7 years of age or Pregnancy-Related/Postpartum Depression): Community Reach Center – English; Spanish
• Health Clinics: Clinica – English, Clinica – Spanish, Mountainland Pediatrics – English, Mountainland Pediatrics – Spanish, Rocky Mountain Youth Clinics; Kaiser – English; Kaiser – Spanish; Kids First Health Care

Care Coordination Documents:

Best practices ensure that, with a family’s permission, all involved parties can support referrals and follow through. Please use this form to help identify who a family might be working with or have as supports in order to identify who you would like to get a Release of Information to notify them of the referral and work together to best support the family:

• Care Coordination – English; Care-Coordination – Spanish

Additional Care Coordination forms and tools:

• Referral Notification Form
• What is the Medical Home Approach and Why Does it Work?
• Referral Checklist

Family Roadmap Brochures:

The Family Roadmap has been finalized! This is a great tool to use when introducing a referral to a family and to ensure that they are informed about the process involved. Contact Stephanie (stephanie@ecpac.org) if you are interested in providing this resource to families.

• Family Roadmap – English
• Family Roadmap – Spanish

Home Visitation Brochures:

Updated documents coming soon

For Additional Resources, visit ECPAC’s Family Resource Websites:

     In English: (/parents-families/)

     En español: (/padres-y-familias/)