The Collaborative for Children and Families Health Home (CCF) 2026

1. Begin by clicking ‘Get Form’ to open the CCF referral facesheet in our editor.
2. Fill in the 'Today's Date' field, followed by the child's full name, including any aliases or nicknames.
3. Enter the child's date of birth and current address, ensuring to include city and ZIP code.
4. Select the child's gender from the provided options: Male, Female, Transgender Male, or Transgender Female.
5. Complete the insurance section by entering the Medicaid/CIN number and county of residence. If applicable, indicate language preference.
6. In the 'Permission to Refer' section, confirm consent has been obtained and specify who granted it. Fill in details for the medical consenter including their relationship to the child.
7. Provide family/residential information and check if any family member is enrolled in another health home.
8. Complete eligibility criteria by checking appropriate boxes based on conditions affecting the child. Attach any supporting documentation if available.
9. Finally, ensure all sections are filled out accurately before submitting via email or fax as instructed at the bottom of the form.

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