{"id":296,"date":"2024-03-22T23:38:51","date_gmt":"2024-03-22T23:38:51","guid":{"rendered":"https:\/\/hca.venturacounty.gov\/public-health\/?page_id=296"},"modified":"2026-06-04T15:27:20","modified_gmt":"2026-06-04T15:27:20","slug":"community-health-nursing","status":"publish","type":"page","link":"https:\/\/hca.venturacounty.gov\/public-health\/community-health-nursing\/","title":{"rendered":"Community Health Nursing"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"296\" class=\"elementor elementor-296\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-717aca2 e-flex e-con-boxed e-con e-parent\" data-id=\"717aca2\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-85f23f4 e-con-full e-flex e-con e-child\" data-id=\"85f23f4\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-766 elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-global elementor-global-766 elementor-widget-icon-list\" data-id=\"766\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;sticky_parent&quot;:&quot;yes&quot;,&quot;sticky&quot;:&quot;top&quot;,&quot;sticky_on&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;],&quot;sticky_offset&quot;:0,&quot;sticky_effects_offset&quot;:0,&quot;sticky_anchor_link_offset&quot;:0}\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/hca.venturacounty.gov\/public-health\/vital-records-and-data\/birth-and-death-registration\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"far fa-arrow-alt-circle-right\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Birth and Death Registration<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/hca.venturacounty.gov\/public-health\/vital-records-and-data\/community-health-nursing\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"far fa-arrow-alt-circle-right\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Community Health Nursing<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/hca.venturacounty.gov\/public-health\/vital-records-and-data\/health-care-for-all\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"far fa-arrow-alt-circle-right\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Health Care for All<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/hca.venturacounty.gov\/public-health\/ems-programs\/medical-marijuana\/\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"far fa-arrow-alt-circle-right\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Medical Marijuana Identification<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-0997dc4 e-con-full e-flex e-con e-child\" data-id=\"0997dc4\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-716ecad e-con-full e-flex e-con e-child\" data-id=\"716ecad\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f2bb764 elementor-widget elementor-widget-heading\" data-id=\"f2bb764\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Community Health Nursing<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-f4b6602 elementor-widget elementor-widget-text-editor\" data-id=\"f4b6602\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><a href=\"https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Breakthrough-Parenting-General-Flyer.pdf\" target=\"_blank\" rel=\"noopener\"><img fetchpriority=\"high\" decoding=\"async\" class=\"alignright wp-image-2286 size-medium\" src=\"https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Breakthrough-Parenting-General-Flyer-002_Page_1-232x300.jpg\" alt=\"\" width=\"232\" height=\"300\" srcset=\"https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Breakthrough-Parenting-General-Flyer-002_Page_1-232x300.jpg 232w, https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Breakthrough-Parenting-General-Flyer-002_Page_1-792x1024.jpg 792w, https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Breakthrough-Parenting-General-Flyer-002_Page_1-768x993.jpg 768w, https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Breakthrough-Parenting-General-Flyer-002_Page_1.jpg 1131w\" sizes=\"(max-width: 232px) 100vw, 232px\" \/><\/a>We work to protect and improve the health of individuals, families, and communities by empowering individuals to achieve optimal health and assuring access to health care. We do this by assessing the needs of individuals across their life span, addressing their concerns, identifying their needs, developing health plans and interventions, and achieving their health goals.<\/p><p>We accept referrals from many sources throughout the community, including physicians, social workers, the general public and you.<\/p><p>Based off your needs, circumstance, or preference you will be assigned a public health nurse that will best support you. If you have any questions regarding eligibility or about the referral process, you may call 805-981-5115.<\/p><p><a href=\"https:\/\/mothersmilk.org\/the-milk-hub\/best-place-to-pump-award\/\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" class=\"alignnone wp-image-2284\" src=\"https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Logo-Transparent-300x151.png\" alt=\"\" width=\"200\" height=\"100\" srcset=\"https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Logo-Transparent-300x151.png 300w, https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Logo-Transparent-768x386.png 768w, https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/04\/Logo-Transparent.png 950w\" sizes=\"(max-width: 200px) 100vw, 200px\" \/><\/a><\/p><p><strong>Community Health Nursing Programs<\/strong><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-627630f e-grid e-con-boxed e-con e-child\" data-id=\"627630f\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-9b11406 elementor-widget elementor-widget-text-editor\" data-id=\"9b11406\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><strong>CALWORKS<\/strong><\/p><p>Supports CalWORKs recipients in the Family Stabilization program with Public Health Nursing (PHN) services, such as health assessments, health education, and resource coordination.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-728e831 elementor-widget elementor-widget-text-editor\" data-id=\"728e831\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><strong>FIELD NURSING<\/strong><\/p><p>Provides community-wide Public Health Nursing services for all ages, with a special focus on maternal and child health.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e180647 elementor-widget elementor-widget-text-editor\" data-id=\"e180647\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><a href=\"https:\/\/hca.venturacounty.gov\/public-health\/nfp\"><strong>NURSE-FAMILY PARTNERSHIP<\/strong><\/a><\/p><p>Offers regular home visits to first-time moms starting early in pregnancy through their child\u2019s second birthday. Public Health Nurses provide support, education, and guidance to promote a healthy pregnancy and strong start for baby and parent.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-5417e6c elementor-widget elementor-widget-text-editor\" data-id=\"5417e6c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><strong>THRIVE<\/strong><\/p><p>Public Health Nurses engage school-age youth involved with SARB, juvenile probation, or at risk of\/experiencing CSEC to support their overall health and wellbeing.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3093d8a elementor-widget elementor-widget-text-editor\" data-id=\"3093d8a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><strong>BABY STEPS TO WELLNESS<\/strong><\/p><p>Supports pregnant women and families with newborns who may be facing challenges like unstable housing, substance use, or health concerns such as syphilis. A PHN and CHW provide health assessment, support, education, and linkage to resources.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-013c6f7 elementor-widget elementor-widget-text-editor\" data-id=\"013c6f7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><strong>ROAD TO RESILIENCE<\/strong><\/p><p>Support pregnant and parenting families with infants under the age of one. Families must be enrolled in with CFS Family Preservation Program. The goal is to help families stay safely together and improve health outcomes. PHNs and other staff work with parents in their homes to strengthen parenting, reduce stress, and connect them to resources.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-9e6f543 elementor-widget elementor-widget-text-editor\" data-id=\"9e6f543\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>If you need help with linking to health care services, have concerns about your child&#8217;s development or your pregnancy or have other health-related questions, please submit a referral to Community Health Nursing. Any questions regarding the referral can be sent to <a href=\"mailto:chnreferrals@venturacounty.gov\">chnreferrals@venturacounty.gov<\/a>.<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-2ecc102 e-con-full e-flex e-con e-child\" data-id=\"2ecc102\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-965a0da e-con-full elementor-hidden-desktop elementor-hidden-tablet elementor-hidden-mobile e-flex e-con e-child\" data-id=\"965a0da\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a5a77d3 elementor-widget elementor-widget-heading\" data-id=\"a5a77d3\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">The Online Nursing Referral form is currently unavailable.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bcb8c0b elementor-widget elementor-widget-text-editor\" data-id=\"bcb8c0b\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Please use the <a href=\"https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/uploads\/sites\/3\/2026\/05\/PHN-Nursing-Referral-Form-5.29.2026.pdf\" target=\"_blank\" rel=\"noopener\">PDF form available here<\/a> and submit by email to <a href=\"mailto:chnreferrals@ventura.org\">chnreferrals@ventura.org<\/a><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7aa457b elementor-widget elementor-widget-shortcode\" data-id=\"7aa457b\" data-element_type=\"widget\" data-e-type=\"widget\" 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adjust them *\/\r\n#gform_wrapper_4 .ginput_container_checkbox{\r\n    display: flex !important;\r\n}\r\n\r\n\/* Set all checkbox fields to display in a row instead of the default column, and add a gray background color*\/\r\n#gform_wrapper_4 .ginput_container_checkbox div{\r\n\tdisplay: flex;\r\n    padding: 5px;\r\n    background-color: #eee;\r\n    text-align: left;\r\n\tflex-direction: row !important;\r\n}\r\n\r\n\/* Set all checkbox fields to flex so we can adjust them *\/\r\n#gform_wrapper_4 .ginput_container_radio{\r\n    display: flex !important;\r\n}\r\n\r\n\/* Set all checkbox fields to display in a row instead of the default column, and add a gray background color*\/\r\n#gform_wrapper_4 .ginput_container_radio div{\r\n\tdisplay: flex;\r\n    padding: 5px;\r\n    background-color: #eee;\r\n    text-align: left;\r\n\tflex-direction: row !important;\r\n}\r\n\r\n\/* Add a horizontal rule above all Section fields *\/\r\n#gform_wrapper_4 .gfield--type-section{\r\n    content: \"\";\r\n    display: block;\r\n    border-top: 1px solid black;\r\n    margin-bottom: 10px;\r\n}\r\n#gform_wrapper_4 .button{\r\n\tpadding-bottom: 0;\r\n\tpadding-top: 0;\r\n}\r\n\r\n\/* This is the checkbox \"Client Aware of Referral\" *\/\r\n#gform_wrapper_4 #field_4_63{\r\n\t\r\n\tposition: relative;\r\n\ttext-align: left;\r\n\ttop: -80px;\t\r\n\tleft: 450px;\r\n}\r\n#gform_wrapper_4 #field_4_27 .ginput_container_checkbox{\t\r\n\tjustify-content: end;\r\n\twidth: 100%;\r\n}\r\n#gform_wrapper_4 #input_4_27{\r\n\tjustify-content: flex-end;\r\n}\r\n\r\n\/* This is the Client Name group\" *\/\r\n#gform_wrapper_4 #field_4_28{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the DOB field\" *\/\r\n#gform_wrapper_4 #field_4_29{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n\tleft: 45px;\r\n}\r\n\r\n\/* This is the Sex Checkbox group\" *\/\r\n#gform_wrapper_4 #field_4_58{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Language dropdown\" *\/\r\n#gform_wrapper_4 #field_4_65{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Insurance field\" *\/\r\n#gform_wrapper_4 #field_4_32{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the MediCal field\" *\/\r\n#gform_wrapper_4 #field_4_33{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Adress group\" *\/\r\n#gform_wrapper_4 #field_4_34{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Phone 1 field\" *\/\r\n#gform_wrapper_4 #field_4_5{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Phone 2 field\" *\/\r\n#gform_wrapper_4 #field_4_35{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Client Email field\" *\/\r\n#gform_wrapper_4 #field_4_2{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Text OK checkbox\" *\/\r\n#gform_wrapper_4 #field_4_62{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Name of Person Living With field\" *\/\r\n#gform_wrapper_4 #field_4_38{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}\r\n\r\n\/* This is the Relationship to Client field\" *\/\r\n#gform_wrapper_4 #field_4_39{\r\n\tposition: relative;\r\n\ttop: -70px;\r\n}<\/style>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Public Health Nursing Referral<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/public-health\/wp-json\/wp\/v2\/pages\/296' data-formid='4' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LdWRXkqAAAAAAH_Qvn6BlAxKFoxONo6JCBtt45z' data-tabindex='0'><input id=\"input_1c9cb9763a57953039690a5d3630d98b\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_1c9cb9763a57953039690a5d3630d98b\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_4' class='gform_fields right_label form_sublabel_above description_below validation_below'><div id=\"field_4_46\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"HCAReferralFormTitle\">\n  <div class=\"indentedText\">\n    <h2>When To Initiate A Public Health Nursing Referral<\/h2>\n    <p>Public Health Nurses (PHNs) will collaborate with you to improve your client\u2019s quality of life and access to care by providing comprehensive nursing assessments, education and linkage to community resources.<\/p>\n    <p>Types of referrals that can be made to Public Health Nursing are:<\/p>\n    <ul>\n      <li>Assistance with access to health care services<\/li>\n      <li>Individuals with multiple medical issues<\/li>\n      <li>Inconsistent, late-entry into or no prenatal care<\/li>\n      <li>At-risk for or currently using harmful substances during pregnancy<\/li>\n      <li>Maternal or postpartum mental health concerns<\/li>\n      <li>Premature births (under 37 weeks gestation)<\/li>\n      <li>Postpartum and breastfeeding support<\/li>\n      <li>Newborn or child prenatally exposed to harmful substances<\/li>\n      <li>Failure to thrive infant<\/li>\n      <li>Concerns regarding infant or child growth and\/or development<\/li>\n      <li>First Time and\/or complicated pregnancy<\/li>\n      <li>Grief Support<\/li>\n    <\/ul>\n    <br \/>\n    <strong>\n      <div>Submissions to this form are reviewed on a non-urgent basis and responses may take time.<\/div>\n      <ul>\n        <li>If this is an emergency or you require immediate attention, call 911.<\/li>\n        <li>If this referral is related to abuse and\/or neglect, call 805-654-3200 to make a report.<\/li>\n      <\/ul>\n    <\/strong>\n  <\/div>\n<\/div><\/div><div id=\"field_4_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION I - Referring Source<\/h3><\/div><div id=\"field_4_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_17'>Date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_4_17' type='text' value='06\/29\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_17_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_17_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_17' class='gform_hidden' value='https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-three-quarter gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_19'>Referring Person &amp; Title:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_4_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"name\" \/><\/div><\/div><div id=\"field_4_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_16'>Agency:<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_4_16' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_21\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_21'>Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_21' id='input_4_21' type='email' value='' class='large'     aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                        <\/div><\/div><div id=\"field_4_22\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_22'>Phone:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_4_22' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_4_23\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-quarter field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_23'>Fax:<\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_4_23' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_57\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Family Stabilization: (For&nbsp;CalWorks&nbsp;Staff&nbsp;ONLY)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_57'>\n\t\t\t<div class='gchoice gchoice_4_57_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Family Stabilization = Yes'  id='choice_4_57_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_57_0' id='label_4_57_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_57_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_57' type='radio' value='Family Stabilization = No'  id='choice_4_57_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_57_1' id='label_4_57_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_25'>CalWorks Case#:<\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_4_25' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_66\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >For Family Preservation (R2R Grant)<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_66'>\n\t\t\t<div class='gchoice gchoice_4_66_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='Yes'  id='choice_4_66_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_66_0' id='label_4_66_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_66_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_66' type='radio' value='No'  id='choice_4_66_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_66_1' id='label_4_66_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_10\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION II - Client Information<\/h3><\/div><fieldset id=\"field_4_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Client Aware of Referral?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_63'>\n\t\t\t<div class='gchoice gchoice_4_63_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='Yes'  id='choice_4_63_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_63_0' id='label_4_63_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_63_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_63' type='radio' value='No'  id='choice_4_63_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_63_1' id='label_4_63_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_4_28\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-seven-twelfths gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_4_28'>\n                            \n                            <span id='input_4_28_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_28.3' id='input_4_28_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_28_3' class='gform-field-label gform-field-label--type-sub '>First:<\/label>\n                                                <\/span>\n                            <span id='input_4_28_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_28.4' id='input_4_28_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_4_28_4' class='gform-field-label gform-field-label--type-sub '>Middle:<\/label>\n                                                <\/span>\n                            <span id='input_4_28_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_28.6' id='input_4_28_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_4_28_6' class='gform-field-label gform-field-label--type-sub '>Last:<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_4_29\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-five-twelfths gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_29'>DOB:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_29' id='input_4_29' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_29_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_4_29_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_29' class='gform_hidden' value='https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_4_58\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Gender:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_58'>\n\t\t\t<div class='gchoice gchoice_4_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='M'  id='choice_4_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_58_0' id='label_4_58_0' class='gform-field-label gform-field-label--type-inline'>M<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='F'  id='choice_4_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_58_1' id='label_4_58_1' class='gform-field-label gform-field-label--type-inline'>F<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_58_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='gf_other_choice'  id='choice_4_58_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_58_2' id='label_4_58_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_4_58_other' class='gchoice_other_control' name='input_58_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_65\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_65'>Primary Language<\/label><div class='ginput_container ginput_container_select'><select name='input_65' id='input_4_65' class='large gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='ENGLISH' >ENGLISH<\/option><option value='ENGLISH CHILD\/SPANISH PARENT' >ENGLISH CHILD\/SPANISH PARENT<\/option><option value='SPANISH' >SPANISH<\/option><option value='FRENCH' >FRENCH<\/option><option value='MIXTECO' >MIXTECO<\/option><option value='MIXTECO\/SPANISH' >MIXTECO\/SPANISH<\/option><option value='TAGALOG' >TAGALOG<\/option><option value='VIETNAMESE' >VIETNAMESE<\/option><option value='ZAPOTECO' >ZAPOTECO<\/option><option value='ZAPOTECO\/SPANISH' >ZAPOTECO\/SPANISH<\/option><option value='UNKNOWN' >UNKNOWN<\/option><option value='OTHER' >OTHER<\/option><\/select><\/div><\/div><div id=\"field_4_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_32'>Type of Insurance:<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_4_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_33'>MediCal #:<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_4_33' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_34\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_4_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_4_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_4_34_1' value=''    aria-required='true'    \/>\n                                        <label for='input_4_34_1' id='input_4_34_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_4_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_4_34_3' value=''    aria-required='true'    \/>\n                                    <label for='input_4_34_3' id='input_4_34_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_34.4' id='input_4_34_4' value='California'\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_4_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_4_34_5' value=''    aria-required='true'    \/>\n                                    <label for='input_4_34_5' id='input_4_34_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_34.6' id='input_4_34_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_4_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_2'>Email:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_4_2' type='email' value='' class='large'   placeholder='please enter client email if known'  aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_4_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_5'>Phone 1:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_4_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_4_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_38'>Name of Person Living With:<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_4_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_35\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_35'>Phone 2:<\/label><div class='ginput_container ginput_container_phone'><input name='input_35' id='input_4_35' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_4_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_39'>Relationship to Client:<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_4_39' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Text OK?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_62'>\n\t\t\t<div class='gchoice gchoice_4_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_4_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_62_0' id='label_4_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_4_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_62_1' id='label_4_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_40\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECTION III - Reason For Referral<\/h3><div class='gsection_description' id='gfield_description_4_40'>Enter all that apply<\/div><\/div><div id=\"field_4_51\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-seven-twelfths field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_51'>Pregnancy?: EDD<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_51' id='input_4_51' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_51_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_51_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_51' class='gform_hidden' value='https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_54\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-five-twelfths field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_54'>Date &amp; Time of next OB appt:<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_4_54' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >First Time Parent? &lt; 28 wks gestation:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_60'>\n\t\t\t<div class='gchoice gchoice_4_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_4_60_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_60_0' id='label_4_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_4_60_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_4_60_1' id='label_4_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_61\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_61'>If postpartum, please enter delivery date:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_61' id='input_4_61' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_4_61_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_4_61_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_4_61' class='gform_hidden' value='https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_4_48\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_48'>Please Specify - Medical diagnoses \/ Identified problem \/ Needs:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_48' id='input_4_48' class='textarea small'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_64\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_64'>Please Specify - Environmental \/ Safety concerns in the home:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_64' id='input_4_64' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_4_56\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='gform_browse_button_4_56'>Upload files as applicable<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_4_56' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_4_56&quot;,&quot;container&quot;:&quot;gform_multifile_upload_4_56&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_4_56&quot;,&quot;filelist&quot;:&quot;gform_preview_4_56&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/hca.venturacounty.gov\\\/public-health\\\/?gf_page=dd0cdb2b681f956&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/hca.venturacounty.gov\\\/public-health\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/hca.venturacounty.gov\\\/public-health\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;205312000b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:4,&quot;field_id&quot;:56,&quot;_gform_file_upload_nonce_4_56&quot;:&quot;501d6ae843&quot;},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;3&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_4_56&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phar&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_4_56' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_4_56' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_4_56\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_4_56'>Max. file size: 196 MB, Max. files: 3.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_4_56'><\/ul> <div id='gform_preview_4_56' class='ginput_preview_list'><\/div><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer right_label'> <input type='submit' id='gform_submit_button_4' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='TxZ5QQdDVEV5KuD\/gXbEpAA06IrOrar5mSvIFg0XxTL+lGlS4Hxk43+Lz4rsWP+3hODfP9mW81qT20oozvHPBrL6av+WMJMc+O5dE0VLLqTkqBc=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_4' value='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' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_4' id='gform_target_page_number_4' value='0' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_4' id='gform_source_page_number_4' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_4' value='' \/>\n        <\/div>\n                        <\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 4, 'https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_4').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_4');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_4').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_4').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_4').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_4').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_4').val();gformInitSpinner( 4, 'https:\/\/hca.venturacounty.gov\/public-health\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [4, current_page]);window['gf_submitting_4'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_4').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [4]);window['gf_submitting_4'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_4').text());}else{jQuery('#gform_4').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"4\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_4\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_4\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_4\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 4, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( 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attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-4456272 elementor-widget elementor-widget-text-editor\" data-id=\"4456272\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><strong>Satisfaction with Nursing Services Survey<\/strong><\/p><p>If you&#8217;ve received services from our nurses, please take a moment to complete our short nursing <a href=\"https:\/\/survey123.arcgis.com\/share\/56e99e0fb239457c8ac30cf3bcf049b4?portalUrl=https:\/\/gis.ventura.org\/portal\" target=\"_blank\" rel=\"noopener\">survey<\/a>. Thanks!<\/p><p><strong>Contact Information:<\/strong><br \/>Veronica Martinez, MSN, RN, PHN<br \/>Program Manager<br \/>805-981-5380<\/p><p>Anna Marie Aguilar, MSN, RN, PHN<br \/>Program Manager, NFP &amp; AFLP<br \/>805-981-5106<\/p><p>Carlotta Davis<br \/>VC MAA &amp; TCM Program Manager<br \/>805-981-5139<\/p><p>Veronica Escobedo MSN, RN, PHN<br \/>Field Nursing and Road to Resilience Clinical Supervisor <br \/>SIDS Coordinator<br \/>805-509-5065<\/p><p>Angela Fulmer, MSN\/MPH, RN, PHN, PHNA-BC, PMH-C<br \/>Nurse-Family Partnership Clinical Supervisor<br \/>805-509-9506<\/p><p>Layne Casillas, BSN, RN, PHN<br \/>THRIVE, CalWORKs, and Baby Steps to Wellness Clinical Supervisor<br \/>Perinatal Services Coordinator<br \/>805-833-0964<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-a241580 e-flex e-con-boxed e-con e-parent\" data-id=\"a241580\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Birth and Death Registration Community Health Nursing Health Care for All Medical Marijuana Identification We work to protect and improve the health of individuals, families, and communities by empowering individuals [&hellip;]<\/p>\n","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_relevanssi_hide_post":"","_relevanssi_hide_content":"","_relevanssi_pin_for_all":"","_relevanssi_pin_keywords":"","_relevanssi_unpin_keywords":"","_relevanssi_related_keywords":"","_relevanssi_related_include_ids":"","_relevanssi_related_exclude_ids":"","_relevanssi_related_no_append":"","_relevanssi_related_not_related":"","_relevanssi_related_posts":"","_relevanssi_noindex_reason":"","footnotes":""},"class_list":["post-296","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/hca.venturacounty.gov\/public-health\/wp-json\/wp\/v2\/pages\/296","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/hca.venturacounty.gov\/public-health\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/hca.venturacounty.gov\/public-health\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/hca.venturacounty.gov\/public-health\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/hca.venturacounty.gov\/public-health\/wp-json\/wp\/v2\/comments?post=296"}],"version-history":[{"count":0,"href":"https:\/\/hca.venturacounty.gov\/public-health\/wp-json\/wp\/v2\/pages\/296\/revisions"}],"wp:attachment":[{"href":"https:\/\/hca.venturacounty.gov\/public-health\/wp-json\/wp\/v2\/media?parent=296"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}