Establishing and Providing Effective Referrals for Clients: A Toolkit for Family Planning Providers

Referrals and Linkages Teen Pregnancy Prevention Program Title X Family Planning Program
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Welcome to the Toolkit

Many individuals describe publicly funded family planning providers as their “usual source of care.”1 In this regard, family planning service sites are often an entry point for other services needed by their clients, and visits may include referrals for other related services. Family planning agencies must provide referrals for medical and social needs that go beyond a site’s scope of services as a core component of furthering the goals of access, equity, and quality in family planning services.2

Picture of provider sitting at table with client

The purpose of this toolkit is to support Title X grantees’ ability to provide effective referrals. It has also been designed to help with oversight of subrecipients in their network who provide referrals. This toolkit provides guidance on setting up systems for consistent provision of referrals. It includes sample policies and strategies for providing high-quality supportive and effective referrals. The toolkit also contains resources for training subrecipients and service sites.

Title X-funded agencies are expected to provide appropriate referrals for medical, informational, educational, and social services related to family planning for clients who want such services.2

Title X grantees, subrecipients, and/or service sites are expected to develop and implement plans to coordinate with and refer clients to other providers of health care and social services, optimally with signed, written collaborative agreements.

Title X agencies should provide for coordination and use of referrals and linkages with, at a minimum:

  • Providers of other health care services not provided on-site (e.g. primary or specialty care such as infertility, infectious disease, prenatal care, pregnancy termination)
  • Other medical facilities (including hospitals) when medically indicated
  • Infant care, foster care, adoption
  • Local health and welfare departments (e.g. SNAP, WIC)
  • Voluntary agencies (e.g., domestic violence, crisis intervention, Alcoholics Anonymous)
  • Ancillary services which may be necessary to facilitate clinic attendance (e.g. childcare, transportation)
  • Health services projects supported by other federal programs, who are in close physical proximity to the Title X site, when feasible, in order to promote access to services and provide a seamless continuum of care.

Title X grantees are expected to have a written policy that requires subrecipients and service sites to have policies for providing needed referrals.

Action Steps Supportive Resources

Develop written policies for providing needed referrals. Sample policy templates can be modified with agency or site-specific information.

Title X Policy Templates

Coordination and Use of Referrals and Linkages

Develop written policy for nondirective counseling and referral. The sample policy template can be modified with agency or site-specific information.

Nondirective Counseling and Referral Sample Policy Template

Nondirective Counseling and Referral Job Aid

Referrals should be provided when a clinical service provider determines that a client has either medical or social service needs beyond the scope of the clinic’s services. Not all referrals, however, require the same level of support to the client.

Referral-making encompasses a spectrum of potential information-giving and supportive behaviors. These range from providing information on specific services to follow-up on service utilization and outcomes and continuous assessment and improvement of the quality of referrals. “Cold” and “warm” are often used to describe referral behaviors at two points along this spectrum.

A cold referral means providing information to the client about another agency or service, and it is then the client’s responsibility to contact the agency or service (for instance, after receiving a business card or name and phone number for a local resource).

A warm referral involves contacting another agency or service provider on the client’s behalf. This entails calling and making an appointment for the client, providing support to overcome barriers to care, and following up to determine if the appointment has been kept.

Agency policies should indicate the type of referral that is usually most appropriate for each service. Referral type may also depend on the client’s individual circumstances, so providers should use their best judgement.

Cold ReferralsWarm Referrals

A cold referral may be appropriate for services like:

  • WIC
  • Weight management treatment
  • Primary care for elevated blood pressure
  • Alcoholics Anonymous

A warm referral may be appropriate for services like:

  • Syphilis treatment
  • HIV-positive test result
  • Prenatal care

A cold referral may be appropriate for clients who:

  • Have reliable internet/phone access, transportation, and housing
  • Can communicate in English (if services are limited to this)
  • Have access to social, financial, and other supports

A warm referral may be appropriate for clients who:

  • Lack reliable internet/phone access, transportation, and housing
  • May experience language barriers/ challenges
  • Lack access to social, financial, and other supports

Referrals for pregnancy options counseling:

If requested to provide such information and counseling, Title X sites are required to:

  • Provide information and counseling regarding each of the following options: a) prenatal care and delivery; b) infant care, foster care, or adoption; and c) pregnancy termination. 
  • Provide neutral, factual information and nondirective counseling on each of the options, and referral upon request, except with respect to any option(s) about which the pregnant client indicates they do not wish to receive such information and counseling.

Source: 42 CFR 59.5(a)(5)

Referrals for pregnancy options counseling:

Title X sites may not:

  • Schedule or arrange for an abortion (warm referral)
  • Provide transportation for an abortion
  • Explain or obtain signed abortion consent forms from clients interested in abortions
  • Negotiate a reduction in fees for an abortion
  • Promote or advocate for abortion

Note: These limitations do not apply in cases in which a referral is made for medical indications.

Source: 65 FR 65 FR (41281-41281)

For more information, see Dobbs v. Jackson Women's Health Organization U.S. Supreme Court Decision: Impact on Title X Program Q&As for Title X Recipients.

Title X agencies should identify other health care and social service agencies serving the same target population to explore whether having an informal or formal relationship may be mutually beneficial. It is important to develop partnerships with community groups, programs, and organizations that represent various sectors and stakeholders, including those addressing social, economic, and environmental factors—the social determinants—that affect sexual and reproductive health.

Action Steps Supportive Resources

Develop partnerships with community groups, programs, and organizations that represent various sectors and stakeholders, including those addressing social, economic, and environmental factors.

Engaging Diverse Community Partners Job Aid

Initiate conversations with key specialists, hospitals, and community services around mutual expectations for referrals. Be prepared to discuss the value of partnering with a Title X agency.

Value Proposition Template

Determine the value-add of potential referral partnerships.

Community Health Workers Building Connections in South Texas: A Case Study Video

Develop a list of local resources, including key contacts at each organization.

Local Resource List

Verify referral information (contact information, hours, location) on an annual basis to ensure that it is current.

A memorandum of understanding (MOU) is a written document, generally not legally binding, that outlines a voluntary agreement between parties. It can facilitate inter-agency communication, coordination of services, and continuity of care for clients. A MOU does not need to include complicated legal conditions, exclusions, indemnifications, etc. It should support the work of the collaboration, not inhibit it.

Action Steps Supportive Resources

Meet with leadership and/or program managers to discuss referral needs and request collaboration.

Develop a written mutual referral MOU, if during the meeting this is determined to be appropriate.

Title X Sample MOU Template

Mail a cover letter and draft MOU, requesting a response with signatures to indicate approval of the collaboration.

Sample MOU Introductory Letters for Family Planning Referrals

Providing high-quality referrals involves assessing individual clients’ circumstances, identifying potential barriers, and helping them to problem-solve and reduce all barriers, therein increasing their ability to access referral services. Without support, clients may receive referral information, but still not access services. Some of the many barriers Title X clients face in accessing services are related to:

  • Finances
  • Language
  • Transportation
  • Lack of child care
  • Age-based consent issues
  • Legal and policy
  • Fear of a lack of privacy
  • Fear of judgement
  • Fear of scorn, intimidation, coercion, or threats
  • Fear of disclosing immigration status

Ensure staff have adequate training and support to help clients with ways to overcome these barriers so they can access the services they need.

Staff must be prepared to provide appropriate referrals and training, identify roles, and develop processes to ensure consistent implementation. 

Action Steps Supportive Resources

Ensure all clinic staff and administration understand the need for and skills related to providing effective referrals.

Providing Effective Referrals Training Guide

Provide frontline staff with an opportunity to practice skills such as:

  • Identify referral needs
  • Speak directly to the referral provider (as appropriate)
  • Provide a verbal and/or written handoff (with the person’s consent)
  • Manage difficult situations
  • Follow up with the client about the referral

Referral Quality Staff Observation Activity, Instructions, and Handouts

Designate staff roles to provide referrals, along with a process for communicating that referrals have been made.

Ensure that referrals and associated processes are well-documented. Close the communications loop for high-priority referrals by establishing clear expectations for client-centered communication while respecting client autonomy and confidentiality. Assess periodically how effective agency referrals are and adjust accordingly.

Action Steps Supportive Resources

Clearly document referrals. Use a standard protocol and consistent documentation for referrals in the medical record. The reason for referral, informed consent of the client, and any correspondence with the referral provider/ organization should be included.

Develop shared referral tools and processes for services that you regularly refer to (and those that regularly refer to you).

Referral Form Template

Close the loop. Determine preferred and acceptable methods of communication and set clear expectations with the client at the time of making the referral.

Track referrals. Use referral management software, EHR downloads, or manually keep a record to ensure effective management of referrals.

If a referral isn’t completed, talk to the client during the next visit to find out why, and document the response. Clients are not obligated to follow up with referral recommendations.

Periodically assess the effectiveness of referral services. Ask clients about their referral experience, and ask the partner agencies about their experience giving and receiving your client referrals.

Patient Experience Improvement Toolkit

  1. Frost JJ, U.S. Women’s Use of Sexual and Reproductive Health Services: Trends, Sources of Care and Factors Associated with Use, 1995–2010, New York: Guttmacher Institute, 2013,, accessed December 7, 2021.
  2. Code of Federal Regulations 42 CFR 59.5. Accessed December 7, 2021.
  3. Title X Statutes, Regulations, and Legislative Mandates. Accessed December 7, 2021.