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Intake Form

  1. Family Child Health Referral Form

    Spanish Family and Visitor

    Please complete the following information to refer yourself or someone else for Family Child Health Services.

    Rice County Public Health Nurses are available to answer your questions about pregnancy, a new baby, breastfeeding, parenting, immunizations, car seats, healthy homes, community resources, and more.

    If you have any questions or need assistance contact or call 507-332-6111 and ask to speak to a Family Child health Nurse. 

    Discharge summaries or additional information can be faxed to 507-332-5932 or emailed to

    For best results, use Internet Explorer to fill out this form.

  2. Who is completing this form?*
  3. Interpreter Needed*
  4. Family Status
  5. First-time parent ?
  6. Such as new mom/baby visit, prematurity, low birth weight, developmental concerns, prenatal visit, parenting support, etc.

  7. Please let us know of any additional information, comments, or medical considerations.

  8. Leave This Blank: