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Fairfield County Family & Children First Council

Fairfield County Perinatal ClusterConsent for Release of Information

Client Name:Date of Birth:Phone:

Client Address:CityStateZip

Client Email Address:

I authorize the following agencies and/or organizations the right to exchange information regarding case history, psychological and education assessments, treatment, and progress updates in order to develop comprehensive service coordination goals that meet the needs of this client and/or family. Information released under this authorization may be subject to re-disclosure by the recipient of the information.

The agencies/organizations listed below have my permission to exchange/share information while assisting me with services through the Perinatal Services Council. If there are exclusions, please indicate.

Fairfield County ADAMH BoardFairfield County Board of Developmental DisabilitiesFairfield County Department of HealthFairfield County Department of Job and Family Services (specify if there are exclusions)

Child Protective Services
Child Support Enforcement
Community Services

Lancaster-Fairfield Community Action Agency

Early Childhood Programs
Housing Assistance and Supports for Youth
Social Services

Fairfield County Family and Children First
CouncilFairfield County Help Me Grow

Fairfield Medical CenterNew Horizons Mental Health ServicesPickerington Area Counseling OfficeThe Recovery CenterOhio Guidestone

School (specify)

Other Hospital (specify)

Other Agency/Organization
(specify) PDHC (Pregnancy Decisions Health Care)Integrated Services Behavioral HealthMid-Ohio Psychological Services

I understand that I may revoke my consent to release information at any time. This consent form is valid for one year from the date the release is signed or as otherwise stated.

(Client Signature)(Date)

Sign below only if you wish to revoke your consent.

Revocation of consent: I hereby revoke the above consent for release of information.
Upon revocations of consent, further release of specified information shall cease immediately.

(Client Signature)(Date)

1/14/2025

Fairfield County Family & Children First CouncilPerinatal Cluster Enrollment Packet

Client Name (enrollment)Referral Date

Email (enrollment)Date of Birth (enrollment)

Address (enrollment)

City (enrollment)Zip Code

Phone (enrollment)

Texting Permitted?YesNo

RaceGenderPrimary Language

Referring Person/Agency

Possible Services Requested

Family

Mother’s Partner
Mother’s Partner genderMaleFemale

Address (same)Phone (mother’s partner)

May information be shared with them? (mother’s partner)YesNo
Is there another adult living in the home? (i.e. friend/relative)YesNo

Name (other adult 1)Relationship (other adult 1)Phone (other adult 1)
Name (other adult 2)Relationship (other adult 2)Phone (other adult 2)

May information be shared with them? (other adults)YesNo
Child/Children (Please list all children)
Son/Daughter Name (child 1)Age (child 1)Date of Birth (child 1)
Currently resides with (child 1)
Father of child (child 1)
Son/Daughter Name (child 2)Age (child 2)Date of Birth (child 2)
Currently resides with (child 2)
Father of child (child 2)
Son/Daughter Name (child 3)Age (child 3)Date of Birth (child 3)
Currently resides with (child 3)
Father of child (child 3)
Son/Daughter Name (child 4)Age (child 4)Date of Birth (child 4)
Currently resides with (child 4)
Father of child (child 4)

Is client and family in a stable living environment?YesNo

If “no”, please explain your housing situation.

Agency Involvement (check all that apply)

Child Protective Services:Caseworker

Job & Family Services:Services (Job & Family Services)

Court Program:Probation Officer

Mental Health Providers:Agency/Clinician 1

Agency/Clinician 2

Agency/Clinician 3

WIC: In what county?WIC county

Early Childhood Programs (pre-school or home visiting)details

Home Visitor’s Name

Community Action:Services (Community Action)

Other:Agency (other)

Mother’s Health

Is Mother currently pregnant?YesDue Date //No

Is Mother currently receiving OB/GYN Care?YesNo

Physician

What is the name of your planned birthing facility?

Is mother currently using any substances legal or illegal?YesNo

Do you have a Plan of Safe Care (PoSC)?YesNo

If “yes” what substance(s)?

Current Medications

Diagnoses

Insurance Information

Private InsuranceProvider

Financial Information

Annual gross income from MotherEmployer (mother)

Annual gross income from FatherEmployer (father)

Do you receive SNAP (Supplemental Nutrition Assistance Program)?YesNo

Amount per month?

Other income (i.e. child support, retirement, social security etc.)

Mother’s Goal(s) for a safe and healthy pregnancy:updated 3.19.25

Goal 1:

Action: (goal 1)Who: (goal 1)

Outcome: (goal 1)

Goal 2:

Action: (goal 2)Who: (goal 2)

Outcome: (goal 2)

Please write a summary of the client’s needs and services requested from Fairfield County Perinatal Services Cluster.

All referrals should be sent to:

Cassandra Bridgeman, Perinatal Cluster Coordinator
Fairfield County Family and Children First Council
831 College Ave., Suite C Lancaster Ohio 43130
740-652-7287 (Phone) 740-681-5540 (Fax)
Cassandra.bridgeman@fairfieldcountyohio.gov

Referrals will be presented and reviewed at the monthly Fairfield County Perinatal Services Cluster meetings.

Updated: 2/19/20254