Child First Online Referral Form Child First Online Referral Form Referral form for Child First Program – complete and submit online. DATE OF RESQUEST FOR SERVICE:(Required) Month Day Year RFS INFORMATIONFill out name, telephone number and e-mail of person making request for serviceLast Name:(Required) First Name:(Required) Telephone:(Required)Email:(Required) Referral Source:(Required) Self (Caregiver or family) FSOP Court personnel Child welfare/Child Protective Services Child developmental services provider Children’s Advocacy Center Domestic violence agency or shelter Early Head Start Early childcare provider/sponsorship Faith-based organization Family resource & support center Health provider – Obstetric/adult Health provider – Pediatric Hospital/NICU Mental health provider – Adult Mental health provider – Child Home visiting program Public health service/department School system Shelter Social Services Substance abuse program Other Specify Program:(Required) Specify:(Required) Specify Type of Shelter:(Required) Other:(Required) CHILD REFERRED FOR SERVICESLast Name:(Required) First Name:(Required) Address (Street, City, State, Zip):(Required) Phone:(Required)Email:(Required) Child DOB:(Required) Month Day Year Sex:(Required) Male Female Child Race:(Required) Black or African-American White/Caucasian Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander Multiple/Multiracial Unknown/Did not report Child Ethnicity:(Required) Non-Hispanic, Non-Latino, Not of Spanish Origin Non-Hispanic – Caribbean Non-Hispanic – Haitian Hispanic – Cuban Hispanic – Mexican (or Mexican American, Chicano) Hispanic – Puerto Rican Hispanic – South or Central American Hispanic – Other Unknown Language:(Required) English Spanish Portuguese French creole Other Please Specify:(Required) Child insurance status:(Required) Amerihealth Health Choice Healthy Blue Medicaid Direct Private insurance Wellcare United Healthcare Community No medical insurance coverage Unknown ADULT TO BE INVOLVED IN SERVICESIs the adult to be involved in services the same person as above? (Person making referral)(Required) Yes No Name:(Required) Address (Street, City, State, Zip):(Required) Relation to Child:(Required) Birth Father Birth Mother Foster Mother Foster Father Step Mother Step Father Adoptive Mother Adoptive Father Female Relative (e.g. grandma, aunt) Male Relative (e.g. gandpa, uncle) Unrelated female adult Unrelated male adult Mother’s live-in partner Father’s live-in partner Other Will the home visits take place at the child's physical address in CFCR?(Required) Yes No Unknown Address for Home Visits (different from Child's physical address in CFCR)(Required) REASON FOR RFSReasons for Referral (Check all that apply) Basic needs (e.g. housing, heat, food, clothing) Child developmental/educational concerns Child behavioral/emotional concerns at home Child behavioral/emotional concerns at school or child care Child exposure to domestic violence Child exposure to community violence Child abuse/neglect Need for parenting education Imminent risk of recent out-of-home placement Risk of or recent child expulsion from child care or school Homelessness or risk of family eviction Major child/family health concerns Parent/caregiver mental health concerns Parent/caregiver substance abuse Parent/caregiver educational needs Service coordination needs Referral source did not identify a reason None/none listed Other Please describe:(Required) OTHER SERVICES/AGENCIES CURRENTLY INVOLVED WITH CHILD/FAMILYOther Services/Agencies Currently Involved with Child/Family Court personnel Child welfare – Investigation Child Welfare – Alternative services Public support services (e.g. Social services, developmental services) Public health services Domestic violence agency or shelter Early childhood education/childcare Faith-based organization Family resource & support center Health provider – Adult Health provider – Pediatric Home visiting (Healthy Start, Parents as Teachers, Nurse Family Partnerships) Hospital – Emergency Room (ER) Hospital – Obstetrics Mental health provider – Adult Mental health provider – Child Mobile Crisis Shelter – Family Substance abuse program None/none listed Other Please describe:(Required) Reasons for Referral NarrativePlease include events that led to the referral, other agencies involved with the family and relevant family dynamics not captured aboveIs the person filling out this form the(Required) Legal Guardian Referent Source Guardian Consent(Required) As legal guardian of the child being referred, I give permission for this referral to be sent to Family Service of the Piedmont, Inc. and for information to be sent to the Child First National Program Office. I understand that I will be contacted by the Child First affiliate agency directly to learn more about Child First and if it is an appropriate service for my child and my family.Legal Guardian Name(Required) First Last Referent Name(Required) First Last Date(Required) Month Day Year
