PREGNANCY & PARENTING SUPPORT – CORONA PROGRAMS’ REFERRAL FORM

ELIGIBILITY FOR PHS’ PREGNANCY AND PARENTING SUPPORT SERVICES

• See page 2 for program coverage areas.
• Low-income pregnant or postpartum women in need of Home Visiting Services and/or Parenting Support,
especially those a) with a medically high-risk pregnancy, b) who have had a preterm birth and/or baby in
the NICU, or c) are at risk for poor parent-child interaction.
• High-need teenagers and women of childbearing age in need of connection to health and social services, including:
• Prenatal Care • Health Education Workshops • Medical or Dental Care
• Breastfeeding Support and Support Groups • Mental/Behavioral Health
• Health Insurance
• Domestic Violence Support • GED or Continuing Education
• Family Planning
• Early Childhood Development • WIC and Food Support
Instructions: Fully complete Parts 1 and 2, and return via fax at 347-571-2797 or email to
CoronaMCH@healthsolutions.org. Please ensure client has signed below in agreement for us to contact them.

PART 1: PATIENT/CLIENT INFORMATION

Date of Referral: 09/19/2022 Preferred language: Spanish English
■
Name: Hailin Marian Iaviery Pereira Birth Date: 03/30/1996 Age:
165-20 Archer Avenue
Address:
Jamaica
City: NY
State: Zip Code: 11433
Phone #: (347) 360-3766 Additional Phone #: Okay to contact by text? Yes No
■
Ivana Baez
Additional Contact Person (if any):
Additional Contact Phone #: Relationship
(347)446-6668 to Contact: referral source

Pregnant? Yes No
■ First pregnancy? Yes No
■
If yes, what is expected due date? Parenting an infant? Yes No
■

# of weeks pregnant: If yes, what is youngest child’s age (months):

Reason for referral/needed services and special instructions:

Client agrees to provide information above and to be contacted by PHS: Yes ■ No
Patient/Client Signature:
Haylin Laviery (Sep 19, 2022 20:55 EDT) Date: 09/10/22

PART 2: REFERRING AGENCY/ORGANIZATION INFORMATION

Ivana Baez
Referring Staff Name: Title: COO
Agency/Organization Name: Alpha
WellCare Staff Phone: (914) 806-6625
ibaez@alphawellcare.com
Staff E-mail Address:
Do you want PHS to follow up with you regarding referral outcome? ■ Yes No
 PROGRAM DESCRIPTIONS AND ELIGIBILITY

COMADRES
CoMadres’ Community Health Workers support women before, during,
and after pregnancy to be as healthy as possible and to connect to
community resources.
Enrollment Eligibility
Women of childbearing age, any time before, during or after pregnancy.
Program Area
Long Island City (11101), Corona (11368,11369), East Elmhurst (11370), Jackson Heights (11372), and
Elmhurst (11373)

HEALTHY FAMILIES CORONA

Healthy Families Corona is a voluntary home visiting program that
supports families with a variety of services. HFC provides parenting
education, supports positive parent-child interaction, infant and
child development, and connects families to community resources.
Enrollment Eligibility
Any time during pregnancy or as soon as possible following birth, up until the baby turns 3 months old.
Program Area
Corona (11368,11369), East Elmhurst (11370), Jackson Heights (11372), Elmhurst (11373), and Woodside (11377)

NURSE-FAMILY PARTNERSHIP
Nurse-Family Partnership is a home visiting program that empowers
first-time moms to transform their lives and create better futures for
themselves and their babies.
Enrollment Eligibility
Pregnant with first baby, up until 28 weeks and 6 days of gestation.
Program Area
Northern Queens and the Rockaways

PHS USE ONLY

Program: Staff: healthsolutions.org