Skip to main content
University of Arkansas for Medical Sciences
Kids First
UAMSHealth
Jobs
Giving
Quick Links
About Us
Enrollment
Employment
Get Involved
History
Licensure and Accreditation
Meet Our Team
Mission
Services
Day Habilitation
Nutrition Services
Healthy Child Care Arkansas
Occupational, Speech, and Physical Therapy
Nursing Services
Specialized Interventions
Following Baby Back Home
Locations
Fort Smith
Little Rock/IHDP
Lowell
Magnolia
Morrilton
Mountain View
Newport
Pine Bluff
Pocahontas
Searcy
Warren
Families
Referral to Kids First
Family Handbook
Menu
About Us
Enrollment
Employment
Get Involved
History
Licensure and Accreditation
Meet Our Team
Mission
Services
Day Habilitation
Nutrition Services
Healthy Child Care Arkansas
Occupational, Speech, and Physical Therapy
Nursing Services
Specialized Interventions
Following Baby Back Home
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
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
Fort Smith
Little Rock/IHDP
Lowell
Magnolia
Morrilton
Mountain View
Newport
Pine Bluff
Pocahontas
Searcy
Warren
Name of Person Completing This Form
First
Last
Relationship to Child
Child’s Legal Name
First
Last
Child’s Nickname
Child’s Birth Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender/Gender Identity
This item is used for statistical purposes only and will not affect your application.
Male
Female
Other
Child’s Native Language
Interpreter Needed
Yes
No
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Policy Holder Name
First
Last
Policy Holder Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Policy Holder Employer
Employer’s Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
Home
Families
Family Handbook
Referral to Kids First
Search for:
Like Us on Facebook!
Catch the latest news and other information from KidsFirst!
Learn more
Contact Us
UAMS Pediatrics
Kids First Program
501.526.8700