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2. If you or one of your clients have questions about breastfeeding or are struggling, don’t feel discouraged. Breastfeeding can be challenging, especially as a new parent.

   Benton County Public Health is here for every mom, whether choosing to breastfeed, pump or formula feed. We offer the lactation help and support needed to feel empowered in parenting choices.

   Please fill out this form and one of our Certified Lactation Counselors (CLC) or Internationally Board-Certified Lactation Consultant (IBCLC) will be in touch to offer the support needed.

   ** Please note, forms submitted will only be reviewed during business hours. Please contact your health care provider if it is urgent.

4. Client Information
6. Client's Name*
8. Client's Phone Number*
9. Client's Mailing Address
11. Client's Date of Birth
12. Relationship to breastfeeding
14. History of Breastfeeding:*

    1. Yes
    2. No
    3. Unknown
15. Current Status:*

    1. Pregnant
    2. Postpartum
    3. N/A
17. Baby's Name
18. Baby's Date of Birth
19. Birth Weight
21. Any birth complications or health concerns?
23. Gestational Age

    How many weeks pregnant?

27. Referral Source
29. Referred by:

    1. Self
    2. Other
31. Referral Source Name
32. Referral Source - Organization
34. Referral Source - Phone Number

38. Referral Details

40. Reason for Referral:*

    1. Prenatal Education
    2. Interested in breastfeeding education
    3. Pumping Education
    4. Flange Fitting
    5. Difficulty with latch
    6. Poor milk supply
    7. Concerns about baby's weight gain
    8. Sore nipples
    9. Breast problems or pain
    10. Preparing to return to work/school
    11. Other (please specify)
42. Referral Notes:

    Please provide any details that may be helpful to the lactation provider. This may include a summary of what was discussed with client. 

44. Information about other Public Health Services was provided:

    1. Yes (please specify below)
    2. No
    3. Unsure
46. Other Public Health Services discussed:
48. Public Health Nurse Outreach

    Our Benton County Public Health Nursing program can provide information on healthy pregnancies, giving birth, breastfeeding, parenting and other helpful resources. If you are interested, by selecting 'Yes' below, you are giving the Benton County Public Health your permission to release and exchange the following information with the nurses from the Benton County Public Health Nursing Program: 

    - Information collected about me or my child as follows: name, date of birth, address and telephone number. 

    - Information about whether I participate in the WIC program. 

    The Benton County Public Health Nurses will use the information to provide services under those programs if I am eligible and wish to participate. I understand that I do not have to agree to the release of information described in this document. I also understand refusing to sign this authorization will not affect my participation in the WIC Program, will not affect the current or future care I receive from any health care provider, and will not cause any penalty or loss of benefits to which I am otherwise entitled. I may cancel my permission at any time in writing. I understand the written cancelation will not affect information the agency has already released, requested, or received. This authorization will expire one year from today. 

    
    

    I wish to release my information to the Benton County Public Health Nursing Program:

    1. Yes
    2. No
50. Authorization

    By checking the "I agree" box below, you agree and acknowledge that 1) your form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. 4) by signing this form electronically, you are allowing the release of information to the lactation providers on staff.

    1. I agree
52. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
54. Electronic Signature
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field