Referral Form

First Breath Referral Form

Congratulations! You are eligible for the First Breath program. Please tell us a little more about yourself and a First Breath Health Educator will contact you within one week.

Please enter your patient's information below

SiteName
SiteId

Referring staff's name (your name): *This question is required.

1. Which best describes you? (Choose one)
*This question is required.

I am pregnant.
I am a mom with a baby that is less than six months old.
I am a caregiver to a young child and not currently pregnant
My partner is pregnant.

Pregnant women: what is your due date?
New moms: when was your baby born (baby’s birthday)?

(Format: MM/DD/YYYY, for example, August 16 2018 = 08/16/2018) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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I am the child(ren)'s

Please enter an 'other' value for this selection.

2. Please tell us about yourself (Fill out completely)

First Name

Last Name

What is your birthdate? (Format: MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

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Mailing Address *This question is required.

City (If City is not listed in this dropdown menu, please make sure you note it in the "note" section).

Zip

Phone Number 1 (Format: xxx/xxx/xxxx or xxx-xxx-xxxx) *This question is required.

Is it a cell phone or landline?

Alternate Phone Number (Format: xxx/xxx/xxxx or xxx-xxx-xxxx)

Is it a cell phone or landline?

Would you like to receive free text messages from the First Breath program? If yes, enter the best phone number here:

Best time to reach you? (Ex. after 2pm, weekends, etc.)

Email Address This question requires a valid email address.

What is your race? (Check only one)

What is your preferred language

Please enter an 'other' value for this selection.

What is your insurance type?

Please enter an 'other' value for this selection.

3. During the past 90 days, which of the following have you used? (This will be kept confidential)
Check all that apply:
*This question is required.

Tobacco products such as cigarettes, e-cigarettes/vape, cigarillos, chew, dip, snus, etc.
Alcohol such as beer, wine, hard liquor
Cannabis/marijuana such as smoked or vaped products, edibles, dab, or synthetic marijuana
Illicit Substances such as cocaine, heroin, meth
Prescription drug misuse (taking medications that were not prescribed to you by doctor or you are taking differently than prescribed) such as pain relievers, stimulants, or tranquilizers
Prefer not to answer, but would still like to be contacted

4. VERBAL CONSENT (Boxes must be checked)

*This question is required.

Yes, I give permission to Wisconsin Women’s Health Foundation to contact me to offer education and support.
I understand that First Breath is not a substance use treatment provider. (If you need treatment services, talk to your provider or call 2-1-1.)

Consent Date (Format: MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

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Notes

Referral Form - New