M5

MIECHV Child’s Enrollment Tool

Index Parent

To be completed within 90 days of enrollment (for those not enrolled prenatally)

OR within 90 days of infant birth (for those enrolled prenatally)

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Parent ID #:

Name of Index Parent:

To meet the measure, all clients must receive a PHQ-9 screening within 90 days of enrollment or infant birth regardless of whether they are currently receiving or have previously received depression services. Part A: Depression Screening

1.	PHQ-9 completed?

Yes, completed → Date tool completed: / / 20 → Go to Question 1a.

1a. If Yes, result of PHQ-9:

Score of 10 or higher → Go to Part B: Depression Referral.

Score of 9 or lower

No, not completed → Complete Screening at future visit before the 90-day window closes, then complete another M5 form and update in THEO.

Part B: Depression Referral

To meet the measure, client must receive a Referral AND at least one Service if the client scores 10 or higher on the PHQ-9 during a MIECHV screening and is not currently receiving depression services.

2.	If a Score of 10 or higher, did you provide a referral? *See examples below

Yes → Complete M2B-MIECHV Referral Tracking & Follow-up Form.

No, the client is currently receiving services (Clients who are currently receiving depression services do not need to be referred).

*Recommended referral services include:	Internal referral to self or other staff trained in Mothers and Babies intervention; Licensed or licensed-eligible mental health provider (LMHC, LCSW, or LMFT); Medication therapy from a primary care provider, psychiatrist, or women’s health provider. No, other reason → Clients who screen positive should be offered and start/receive at least 1 referral service. Continue to follow up with client at future visits to track referral and follow-up on

M2B-MIECHV Referral Tracking & Follow-up Form.