High risk participants must be identified and referred appropriately to a health care provider, Registered Dietitian (RD), or International Board Certified Lactation Consultant (IBCLC). See CS:33.0 High Risk Referrals policy for guidance.
The following forms were created to assist the local agency staff when providing counseling and referrals to high risk WIC participants. The forms are for sample purposes only.
Client Information for Appointment with WIC High Risk RD (English, Spanish) — This form includes the date and time of the appointment with the WIC High Risk RD, the name and telephone number of the clinic site, a brief description of the services that will be provided, and what to bring to the appointment.
- Client Information for Appointment with WIC HR RD (English, PDF)
- Client Information for Appointment with WIC HR RD (Spanish, PDF)
High Risk Counseling Referral Form (PDF) — This form includes documented information to share with the WIC High Risk RD or other professional regarding the reason for the referral; it may also be used internally to document and track the referral. In addition, the form may be used to document refusal of referral services. There is a place for the HR participant to sign if they refuse to accept the referral services.
High Risk Appointments and Tracking (PDF) — This form may be used to schedule appointments with the WIC High Risk RD and to track outcome.
Summary and Tracking of High Risk Referrals (PDF) — This form allows the local agency to document all referrals, including the date identified, client identification, reason for referral and to whom the referral was made, e.g. WIC HR RD, outside RD, MD, ECI, and other.
Summary of High Risk Referrals/Outcomes and Tracking (PDF) — This form is very similar to the Summary and Tracking of High Risk Referrals, however, it does not provide space to list “reason for referral.” It does include outcome documentation codes and columns.
For more information, contact Stephanie Holland, RD, LD, Nutrition Education Program Specialist, at 512-341-4577 or Stephanie.Holland1@hhsc.state.tx.us.