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California Family Health Council, Inc.

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Samples File: Forms

Pregnancy Testing and Counseling Forms

All sample forms include basic questions to fcilitate obtaining and documenting appropriate and adequate history and intervention. They vary, however, in the amount of information obtained and protocol guidance given to staff. In addition, one of the forms is designed for client self administration.

Samples #1, #2, #3, and #5 have been removed. They are being updated and will be reposted.

Sterilization Forms

Should you choose to use your Title X funds to support sterilization services, you must use the OMB federal sterilization consent forms. Forms are available online from the HHS website; scroll down the page for PDF or Microsoft Word format.

CFHC invites agencies to make their materials available to others throughout the Title X system. This can be arranged by contacting Barbara Kass-Annese, RNCNP, MSN, Medical Specialist, Clinical & Commmunity Health Programs at 213-386-5614 x4567, email kass-anneseb@cfhc.org.

Visit the FPCPP websiteVisit Healthed.org for more trainings and conferencesJoin a research study at testmethods.orgSee resources just for our Title X clinics.

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