Risk Screens & Referral Form


The Florida Universal Prenatal Screen is the first step in introducing your patients to the many supportive services of the Healthy Start Program.

The Florida Healthy Start Infant Risk Screen is a concise questionnaire aiding birthing facilities in identifying infants at risk for adverse health outcomes and mortality.

The Florida Healthy Start CONNECT Referral Form easily connects pregnant women to the Healthy Start CONNECT program for free resources and services.


How to access the Florida Universal Prenatal Screens and Referral Form?

If your office needs more Florida Universal Prenatal Screens or Referral Forms, please contact your local Provider Liaison, Yadiris Romero at yromero@healthystarthhp.org, or click any of the buttons below to download a .pdf.

What to do once the Florida Universal Prenatal Screen & Infant Risk Screens are completed?

Once the screen is completed discuss with your patient what her score means. Explain to her how she and her baby can benefit from Healthy Start Services. Then follow the process listed below.

  1. Give a photocopy to the patient.
  2. Keep a copy in the patient’s chart.
  3. Fax a copy to a secure fax line at 863-837-1484 OR mail the original to the address listed below within 5 days.

Florida Department of Health in Polk County

1290 Golfview Avenue – 4th Floor
Bartow, FL 33830

Florida Universal Prenatal Screen Downloads

Infant Risk Screen Downloads

CONNECT Referral Form Download

Contact Us

We are here to support you.