Date of Referral:
Applicant Date of Birth:
Applicant Age:
Applicant Sex:
Is the applicant pregnant?
Is the applicant a Mississippi Resident?
County of Residence:
M-D-Y
M-D-Y
Male Female Other Prefer Not To Say
Yes
No
View equation Is the applicant a Mississippi resident?
Yes
No
Adams Alcorn Amite Attala Benton Bolivar Calhoun Carroll Chickasaw Choctaw Claiborne Clarke Clay Coahoma Copiah Covington Desoto Forrest Franklin George Greene Grenada Hancock Harrison Hinds Holmes Humphreys Issaquena Itawamba Jackson Jasper Jefferson Jefferson Davis Jones Kemper Lafayette Lamar Lauderdale Lawrence Leake Lee Leflore Lincoln Lowndes Madison Marion Marshall Monroe Montgomery Neshoba Newton Noxubee Oktibbeha Panola Pearl River Perry Pike Pontotoc Prentiss Quitman Rankin Scott Sharkey Simpson Smith Stone Sunflower Tallahatchie Tate Tippah Tishomingo Tunica Union Walthall Warren Washington Wayne Webster Wilkinson Winston Yalobusha Yazoo
Based on the information you provided, below are the following programs that may fit your needs.
Please select the program area that you would like to complete a referral for.
To complete a program referral, please click the checkbox at the bottom of each program description.
The Mississippi State Department of Health's Children and Youth with Special Health Care Needs Program (CYSHCN) provides care coordination services for children and youth ages 0 to 21.
Care coordinators work to connect families with the resources that are right for their needs.
·Eligibility requires documentation of a diagnosed chronic condition and a referral form.
The First Steps early intervention program supports families of infants and toddlers under three years of age who have a developmental delay, or who have a diagnosed condition that's likely to cause delays in development.
WIC is a special supplemental food program for pregnant, breastfeeding, and post-partum women, infants, and children under five years of age. WIC helps you and your baby get healthy foods and healthy advice in the first years of life.
The Mississippi State Department of Health, Healthy Moms/Healthy Babies of Mississippi (HM/HB) is a maternal and infant health support program working with families and communities to help ensure that all Mississippi moms and babies have safe birthing experiences and healthy infant development.
The HM/HB program partners with the medical home and community to provide care coordination and home visiting services to assist moms and babies who have identified health risks. The HM/HB Nurse Case Manager provides a comprehensive assessment helping to identify patient's needs, develop a plan of care, and coordinate services to address medical, social, and dietary needs. MSDH has extended service providers such as nurses, social workers, and registered dieticians that may help with:
• Finding a medical home for mom and/or her baby
• Identifying family and community supports
• Referrals for services such as Medicaid, food stamps (SNAP) and WIC
• Referrals for family planning, mental health, transportation, housing, medical services, childcare, employment services, and breastfeeding assistance
• Postpartum home visits
• Health education, such as preparing for the hospital, urgent maternal warning signs, depression, anxiety, caring for baby, infant safety, and healthy infant development
The Early Hearing Detection and Intervention Program in Mississippi (EHDI-MS) works with health care providers, including birthing hospitals, midwives, audiologists, otolaryngologists, primary care providers, and early intervention providers to ensure that:
All infants born in Mississippi receive a hearing screening by 1 month of age; Infants are referred for hearing diagnosis by 3 months of age when screening indicates it; Infants with confirmed hearing loss receive early intervention services by 6 months of age. Infants who are at risk for late onset or progressive hearing loss receive ongoing follow-up to identify any hearing loss that may develop.
The purpose of the Northeast Mississippi Healthy Start Program is to improve health outcomes of women and their families before, during, and after pregnancy. Through enabling and direct clinical services, the program also provides resources aimed at decreasing infant and maternal morbidity and mortality and adverse perinatal outcomes. Participants enrolled in the Healthy Start program will receive health-related care and resources to improve overall health and wellbeing. Participants for this program include males and females in childbearing ages (13-44), pregnant and post-partum women, and infants & children up to 18 months of age.
MIECHV-MS Program supports pregnant women and parents with younger children who live in communities that face greater risks and barriers to achieving positive maternal and child health outcomes. Families choose to participate in home visiting programs, and partner with health, social service, and child development professionals to set and achieve goals that improve their health and well-being.
The program aims to:
Improve: maternal and child health Prevent: child abuse and neglect Reduce: crime and domestic violence Increase: family education level and earning potential Promote: children's development and readiness to participate in school Connect: families to needed community resources and supports
Newborn screening is a blood test that can identify the most common genetic disorders.'
Within 24-48 hours after birth, newborns are tested at birthing facilities to detect underlying genetic conditions. Abnormal test results warrant follow-up for further testing, initiates medical referral(s) for prompt treatment, and tailored intervention(s) for individualized care.
'Early screening is the only way to detect genetic abnormalities, prevent permanent damage , and provide better health outcomes.'
Web Reference:
Newborn Screening and Genetic Services - Mississippi State Department of Health (ms.gov)
The MSDH Oral Health Program strives to:
To provide access to dental services and obtain a dental home for those who may or may not have dental insurance. To inform those who are covered by Medicaid but are unaware of Medicaid's dental coverage of their benefits.
Person Completing the Referral: Referral Source Phone: Referral Source Email: Referral Source Fax: Name of Applicant: Birth Name (if different):
If Child, Legal Guardian Name: If Child, Legal Guardian Name:
Home Phone: Cell Phone: Work Phone:
Physical Address: City: County: Zip Code: Ethnicity: Race:
Primary Care Provider/Pediatrician First Name: Primary Care Provider/Pediatrician Last Name: Primary Care Provider/Pediatrician City: Primary Care Provider/Pediatrician Phone: Medical Coverage:
CPS Custody/CAPTA:
Primary Language:
Yes No
Hispanic/Latino
Non-Hispanic/Latino
English
Spanish
Other
Adams Alcorn Amite Attala Benton Bolivar Calhoun Carroll Chickasaw Choctaw Claiborne Clarke Clay Coahoma Copiah Covington Desoto Forrest Franklin George Greene Grenada Hancock Harrison Hinds Holmes Humphreys Issaquena Itawamba Jackson Jasper Jefferson Jefferson Davis Jones Kemper Lafayette Lamar Lauderdale Lawrence Leake Lee Leflore Lincoln Lowndes Madison Marion Marshall Monroe Montgomery Neshoba Newton Noxubee Oktibbeha Panola Pearl River Perry Pike Pontotoc Prentiss Quitman Rankin Scott Sharkey Simpson Smith Stone Sunflower Tallahatchie Tate Tippah Tishomingo Tunica Union Walthall Warren Washington Wayne Webster Wilkinson Winston Yalobusha Yazoo
The option "
Person Completing Referral
Do you or the child live in or frequently visit a home built before 1978?
* must provide value
Yes No I don't know
Do you or the child live in a household with someone who works with lead? Examples include construction, painting, welding, mechanic, visiting recycling centers, or bullet manufacturing.
* must provide value
Yes No I don't know
Does your tap water come from a well?
* must provide value
Yes No I don't know
Does the child put objects in their mouth like keys, electrical cords, jewelry, vinyl (plastic) mini-blinds or bare soil outside near the home?
Yes No I don't know
Does the infant have a safe sleep environment?
* must provide value
Yes No N/A (Child is over 12 months of age) I don't know
Is there a child in the home with an elevated blood lead level?
* must provide value
Yes No I don't know
Do you or the child live in a household with someone who has a hobby related to lead? Examples - ceramic/pottery and fishing.
* must provide value
Yes No I don't know
It appears you have selected "I don't know" for 1 or more of the questions. For additional information, please contact the Lead Poisoning Prevention and Healthy Homes Program at 601-576-7447.
Have you had a baby in the past 18 months?
Yes No Unknown
Please select the baby's age range.
Under 12 months 12 months - 18 months of age
Do you currently have a baby 18 months of age and younger?
Yes No Unknown
For more information regarding the Northeast Mississippi Healthy Start Program and/or assistance regarding this referral, contact Caroline Petty at 662-328-1174 or by email at Caroline.Petty@msdh.ms.gov.
Are you concerned about the child's hearing?
* must provide value
Yes No
Has the child had a hearing evaluation?
* must provide value
Yes No Unknown
If you have any questions or concerns about the child's hearing, contact our program.
Phone (601) 576-7427 or 1-800-451-3903 Email: EHDI@msdh.ms.gov Does the child have confirmed hearing loss and/or ear malformation?
* must provide value
Yes No Unknown
Please select the ear(s) with hearing loss and/or ear malformation.
* must provide value
Left Right Both Unknown
Left Ear
Degree of Hearing Loss:
Type of Hearing Loss:
Ear Malformation?
Left Degree of Hearing Loss
* must provide value
Slight (16 - 25 dB) Mild/Minimal (26 - 40 dB) Moderate (41 - 55 dB) Moderately Severe (56 - 70 dB) Severe (71 - 90 dB) Profound (>90 dB) Unknown
Type of Hearing Loss
* must provide value
Nontransient Conductive Transient Conductive Sensorineural Mixed ANSD Unknown
Ear Malformation
* must provide value
Yes No Unknown
Right Ear
Degree of Hearing Loss:
Type of Hearing Loss:
Ear Malformation?
Right Degree of Hearing Loss
* must provide value
Slight (16 - 25 dB) Mild/Minimal (26 - 40 dB) Moderate (41 - 55 dB) Moderately Severe (56 - 70 dB) Severe (71 - 90 dB) Profound (>90 dB) Unknown
Right Type of Hearing Loss
* must provide value
Nontransient Conductive Transient Conductive Sensorineural Mixed ANSD Unknown
Right Ear Malformation
* must provide value
Yes No Unknown
The option "
Select any of the following that apply to the applicant.
It appears you may not be eligible for WIC services. If you have any questions or feel this is an error, please contact the WIC Office at 1-800-338-6747.
Yes No Unknown
Do you have a child with special health care needs age birth to 21?
Yes No
Does the applicant have a chronic condition diagnosed by a medical doctor?
Yes No Unknown
Specify Diagnosed Chronic Medical Condition(s)
* must provide value
If you have any questions or concerns contact our program.
Phone 1-800-844-0898 Email: CYSHCN@msdh.ms.gov Has the infant reached 9 months of age?
Yes No Unknown
Please select all that apply for the infant.
Please describe birth defect(s) or concerns.
* must provide value
Please describe other risk factors not listed above.
Please select all that apply for the mother.
History of preterm birth
History of low birth weight baby(ies)
Multiple gestation
Fetal complications, SPECIFY:
Chronic conditions which may complicate pregnancy (Diabetes, Hypertension, HIV, SLE - Systemic lupus erythematosus, Sickle Cell, Asthma, Seizure Disorder, Renal disease, Substance abuse diagnosis), SPECIFY:
Mental health condition
Unsafe living environment (Homelessness, Inadequate housing, Violence or abuse)
Substance use
Tobacco use
Missing two or more prenatal appointments without rescheduling
Late entry to prenatal care
Hospital Utilization during the first two trimesters
Nutrition Deficiency affecting Pregnancy
Teen Pregnancy
Other risk factor(s) not listed, SPECIFY:
Please describe fetal complications.
Please describe chronic conditions.
Please describe other risk factors not listed.
Do you have a child with special health care needs age birth to 21?
Yes No
Diagnosed Conditions and Other Concerns for All Referrals
Please describe your concerns.
Specify Prenatal exposure
Suspected Developmental Delay
If you have documents or medical records you would like to upload with this referral, please do so using the link below.
Was the infant born within the last 48 hours?
* must provide value
Yes No
Was the infant born in a hospital or a home birth?
* must provide value
Hospital Home Birth Unknown
Are the infant's parent(s) transient?
* must provide value
Yes No Unknown
It appears the infant may not be eligible for Genetic/Newborn Screening services due to the infant not being born within the last 48 hours.
If you have any questions or concerns about genetic services or the infant's newborn screening, please contact the infant's primary care provider or our program (MSDH Genetic Services) at (601) 576-7619.
Please select all birth defects or genetic disorders.
Stomach/Intestine Defects
Chromosome (Gene) Defects
Critical Congenital Heart Defects
Has the applicant had a dental visit in the last six (6) months?
Yes No
Does the applicant have a dental home?
Yes No
May we contact you or the applicant about finding a dentist?
Yes No
Please provide the reason for the dental referral.