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Families
- Referral to Kids First
- Family Handbook

About Us
Services
Locations
- Fort Smith
- Little Rock/IHDP
- Lowell
- Magnolia
- Morrilton
- Mountain View
- Newport
- Pine Bluff
- Pocahontas
- Searcy
- Warren
Families
- Referral to Kids First
- Family Handbook

Referral to Kids First

Home
- Families
  - Family Handbook
  - Referral to Kids First

Referral to Kids First

Please fill out this form to start the referral process with Kids First. If you would like to finish the form later, click the Save and Continue Later link at the bottom of the form.

Clinic Location
Name of Person Completing This Form
First Last
Relationship to Child
Child’s Legal Name
First Last
Child’s Nickname
Child’s Birth Date
Gender/Gender Identity
This item is used for statistical purposes only and will not affect your application.
Child’s Native Language
Interpreter Needed
- Yes
- No
Address
Street Address Address Line 2 City State ZIP Code
Who referred you to Kids First?
Do you know why they referred you to Kids First? Please explain.
What are your main reasons for seeking services for this child at UAMS Kids First?
Has your child ever received/been enrolled in:
- Development Therapy/Day Treatment/Early Intervention
- Occupational Therapy
- Behavioral or Counseling Services
- Physical Therapy
- Nursing/Home Health
- Child Care/Preschool
- Speech Therapy (ST)
- Hospice
- Home Visiting Programs
- No, my child hasn’t received any of the services listed above
If you checked one of the boxes above, where has your child received services?
Is your child currently receiving any of the services above?
- Yes
- No
Family/Guardian Information
Parent/Guardian Name 1
First Last
Relationship to Child:
- Parent
- Legal Guardian
- DHS Caseworker
- Other
If you selected other, please enter relationship below:
Contact Phone - Mobile
Contact Phone - Home
Email
Enter Email Confirm Email
Parent/Guardian Address
Street Address Address Line 2 City State ZIP Code
What’s the best way to contact you?
- Mobile phone
- Home phone
- E-mail
- Text
What’s the best time to contact you?
Parent/Guardian Name 2
First Last
Relationship to Child:
- Parent
- Legal Guardian
- DHS Caseworker
- Other
If you selected Other, please enter relationship below:
Contact Phone - Mobile
Contact Phone - Home
Email
Enter Email Confirm Email
Parent/Guardian Address
Street Address Address Line 2 City State ZIP Code
What’s the best way to contact you?
- Mobile phone
- Home phone
- E-mail
- Text
What’s the best time to contact you?
Are there any custody issues that we should be aware of?
Emergency Contact Information
Contact Name
First Last
Contact Phone
Contact Street Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child’s Healthcare Coverage
Insurance: Does the child have:
- Commercial
- Medicaid
- None
Insurance Company
Benefits Phone Number
Address of Insurance Company
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Policy Holder Name
First Last
Policy Holder Date of Birth
Policy Holder Employer
Employer’s Address
Street Address Address Line 2 City State ZIP Code
Child’s MCD Number:
Health Screening
Tell us about your child’s health history
Has your child ever been hospitalized?
- Yes
- No
If yes, describe:
Does your child currently take any prescription medications? If yes, please list the drug name and dose
Does your child take any over the counter medications, vitamins, or other supplements?
Is your child current on their immunizations?
- Yes
- No
Allergies
- Food Allergies
- Drug Allergies
- Other
Please list food allergies
Please list drug allergies:
Please list other allergies:
Who else provides health care services for your child?
Fill in any that apply.
Primary Care Doctor
Date of Last Appointment
Specialty Care (like Cardiologist, Neurologist, etc.)
DME (company that ships medical supplies to your house)
WIC Clinic Location
Does your child require any of the following?
- Oxygen
- CPT
- Urinary Caths
- Splints/Braces
- Seizure Precautions
- Pulse Ox
- Breathing Treatments
- Feeding Device
- Corner Chair
- Reflux Precautions
- Suction
- Hearing Aids
- Wheelchair
- NG/OG/GT
- Trach Care
- Eye Glasses
- Communication Device
- Apnea Monitor
- Weight Checks
- Prosthesis
- Stander/Walker
- Other
If other, please explain:
Prenatal Care and Pregnancy
When did prenatal care begin?
- None
- First Trimester
- Second Trimester
- Third Trimester
- Unknown
Were there any complications?
- Gestational diabetes
- Hypertension
Did the child’s mother use any of the following while pregnant?
- Alcohol
- Cigarettes
- Drugs
- Medications
If you clicked any of the above, list types and amounts of each
Birth History
Birth was:
- Full Term
- Preterm
If born preterm, what was the gestational age?
Delivery
- Vaginal Delivery
- C-Section
Birth Weight
Did the child require any of these after birth?
- Resuscitation
- Intensive Care Nursery (NICU)
How long was the stay in the hospital?
Mother
Baby
Hospital name
Was the child transferred to another hospital? If so, where?
Do the child’s family members have any of the following health conditions?
- Hypertension
- Diabetes
- Cigarette Use
- Obesity
- Behavioral/Psychiatric Disorder
- Dyslipidemia
- Cardiovascular disease in men <55 or women
- Other
If other, please specify:
Have the child’s parents or siblings had any of the following?
- Blindness/vision loss
- Amblyopia (“Lazy Eye”)
- Strabismus (“Crossed Eye”)
- Eye Muscle Surgery
- Glasses before age 4
- Cataracts in childhood
- Glaucoma in childhood
- Other
If other, please specify:
Tell us about how your child eats:
- Breastfed
- Cup
- Bottle
- Bottle only
- Tube fed
- NPO
- Therapeutic feeds only
- Baby foods
- Some table foods
- Regular diet
Tube feeding regimen
If applicable, list formula type and amount/schedule
Special diet instructions:
Thickened liquids:
- Nectar
- Honey
- Paste
- N/A
Thickener
- Simply Thick
- Thick-It
- Thick-It 2
- Rice Cereal
- N/A
Does your child have any of the following?
- Delayed feeding skills for age
- Gagging/choking
- Reflux
- Poor appetite
- Difficulty chewing
- Problems sucking
- Diarrhea
- Aspiration risk
- Limited variety of foods
- Difficulty swallowing
- Constipation
- Herbal/nutritional supplements
- Pica (eats non-food items)
- Dental caries
- Bottle to bed
- Food allergies/intolerances
Development and Behavior
Do you have any concerns about your child’s behavior? If so, please describe:
Has anyone else expressed any concerns about your child’s behavior? If so, please describe:
Has your child ever been suspended or expelled from a child care/preschool for their behavior? If so, please describe:
Do you have any concerns about your child’s development?
Comments
This field is for validation purposes and should be left unchanged.

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