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Healthy Families AZ Referral

HFAz Referral

Caregiver's First Name *

Caregiver's Last Name *

Caregiver's Email *

Caregiver's Phone Number *

Question for Caregiver: Are you pregnant? *

Expected Due Date *

Month

Day

Year

Question for Caregiver: Do you have a child that is 3 months old or less? *

Child's Name (1) *

Child's Date of Birth (1) *

Month

Day

Year

Child's Name (2)

Child's Date of Birth (2)

Month

Day

Year

Sorry, you do not qualify

For eligibility questions, please email [email protected].

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Caregiver's Street Address *

Caregiver's Zip Code *

Caregiver's County *

Maricopa County Residents: Select the option that contains your zip code *

85042, 85043, 85045, 85256, 85323, 85326, 85329, 85338, 85339, 85340, 85353, 85392, 85395, 85396

85006, 85010, 85012, 85014, 85016, 85018, 85020, 85048, 85053, 85127, 85142, 85208, 85209, 85212, 85213, 85216, 85226, 85233, 85234, 85248, 85249, 85250, 85283, 85284, 85286, 85295, 85296, 85297, 85298

85022, 85023, 85032

85003, 85004, 85007, 85008, 85009, 85013, 85015, 85017, 85019, 85021, 85024, 85027, 85028, 85029, 85031, 85033, 85034, 85035, 85037, 85040, 85041, 85044, 85050, 85051, 85083, 85085, 85201, 85202, 85203, 85204, 85205, 85206, 85207, 85210, 85224, 85225, 85251, 85253, 85254, 85255, 85257, 85258

85259, 85260, 85262, 85263, 85264, 85266, 85268, 85281, 85282, 85301, 85302, 85303, 85304, 85305, 85306, 85307, 85308, 85310, 85331, 85335, 85345, 85351, 85355, 85361, 85363, 85373, 85374, 85375, 85378, 85379, 85381, 85382, 85383, 85387, 85388

Pinal County Residents: Select the option that contains your zip code

85117, 85118, 85119, 85120, 85140, 85144, 85173, 85178

85122, 85123, 85128, 85130, 85131, 85132, 85138, 85139, 85141, 85143, 85148, 85172, 85193, 85194

Preferred Language *

Is this referral being submitted on behalf of the Caregiver? *

Name of Provider submitting the referral *

Email of Provider *

By submission of this form, I/we authorize the Department of Child Safety (DCS) to release the above information on a need-to-know basis to Healthy Families AZ service providers. Submission of this form indicates the caregiver is aware that a Healthy Families AZ referral is being submitted and the caregiver agrees to be contacted from a designated Healthy Families service provider and/or the DCS Healthy Families AZ Coordinator.

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Arizona Department of Child Safety

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