Family Support Services

We keep your information private

Please correct the errors described below.

Emergency Assistance

If this is an emergency, call:

Referral Type

I am referring myself I am referring someone else

Client or Parent Information

First name

Last name

Address

Cell phone number

Email address

Date of birth

Child's Information (if services for child)

First name

Last name

Date of birth

Referring Partner/Provider (if applicable)

First name

Last name

Email adress

Phone number

Reason for referral

Please mark which type of services you are requesting.

Children 0-5 years

Children with Special Needs

Breastfeeding

Pregnancy/Post-partum

Type of insurance.

Oregon Health Plan (OHP)

Private Insurance

Other

None

Unknown

Is the client or family receiving WIC?

Yes

Don't know

Is there anything else you would like us to know?

By checking this box, I agree to have an employee from Hood River County Health Department contact the client/parent.

Note to providers: Medical records or other referral documents may be upload here and are kept confidential.

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Emergency Assistance

If this is an emergency, call:

Kate Karlson, RN, BSN, PMH-C, CLC

Maternal Child Health Nurse, Hood River County Health Department

541-387-7119 (desk), 541-386-1115 (main clinic #)

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