Enroll

Your Name (required)

Your Phone Number (required)

Your Address

Have You Previously Been Enrolled in CHIP?
YesNo

Locality
Bedford CountyBotetourt CountyCraig CountyRoanoke CityRoanoke CountySalem City

Primary Language (required)
EnglishSpanishOther - Specify

Gender
MaleFemaleNon-binary

Relationship
MotherFatherLegal GuardianFoster ParentOther

Number of Adults in the Home

Number of children in the Home

Is anyone in the family pregnant?
YesNo

Is there a newborn in the family (0-3mo)?
YesNo

Insurance
MedicaidOtherUnknown

Available Services (check all that apply)

Support In
Accessing & Understanding health careBasic needs: clothing, food, transportation, housingBecoming self-sufficientChoosing a medical homeCoordinating servicesFinding InsuranceKeeping up to dat on well child visits/immunizationsMental Health services for caregivers & children

Information On
Baby/postpartum careHealthy living for parents & childrenHealthy pregnancy & childbirthHome safetyKindergarten readinessParent/child play activity ideasParenting tipsPositive discipline/routnes for children

Concerns About
Child's developmentCognitive impairment: ParentDomestic ViolenceHistory of child abuse/neglectMedical condition of childMedical condition of parent/caregiverSingle parentSubstance useTeen parent

Is there anything else CHIP should know?

Referral completed by (please provide a telephone number and email so we may contact you if needed)

Name (required)

Organization

Phone Number (required)

Email (required)