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High Risk Referral Process

High risk participants must be identified and referred appropriately to a health care provider, Registered Dietitian, or International Board Certified Lactation Consultant. 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 and are in the process of being revised.

Client Information for Appointment with WIC HR RD (English, Spanish) — This form includes the date and time of the appointment with the WIC HR 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.

High Risk Counseling Referral Form — This form includes documented information to share with the WIC HR 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 refusal to accept the referral services.

High Risk Appointments and Tracking — This form may be used to schedule appointments with the WIC HR RD and to track outcome.

Summary and Tracking of High Risk Referrals — 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 — 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,” but includes outcome documentation codes and columns.

High Risk Individual Counseling Resources


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Last updated April 26, 2018