Family Partners Referal Form

PHILLIPS’ FAMILY PARTNERS Programs for Children and Families 7010 Braddock Road Annandale, VA 22003 Phone: (703) 658-9054 Fax: (703) 658-9056 Contact: Sandy Porteous, MA, Program Director Please return referral form to: [email protected]

Date of Referral: ______

Name of Referring Worker______

Agency: ______

Phone Number______Fax Number: ______

Address: ______

County: ______City: ______State: ______Zip: ______

Is the case Medicaid? yes _____ No If yes, please give Medicaid #:______

Has the family been approved by FAPT/CAT? _____Yes _____No

Will this be mandated or non-mandated funds? ______

How many hours have been approved? ______

What services were approved?

_____ Home-based _____ Outpatient Therapy _____ Mentoring

_____ Behavior Management (BCBA/LBA) ____ Behavior Management (ABA Specialist)

_____ Out of home respite _____ Supervised Visitation ____ In-home respite

Has the family been informed that you are referring them to Family Partners? ____Yes ____No FAMILY

Family Name: ______

Address where child is currently living: ______

County: ______City: ______State:______Zip:______

Telephone Number: ______

IDENTIFIED DATE OF M/F SOCIAL SECURITY CHILD’S/CHILDREN’S BIRTH NUMBER NAME

Where is the child(ren) living now?: (please check one)

______At home with Parent/Guardian ______Diagnostic Group Home ______Relatives Home (informal) ______Detention Center ______Relatives Home (foster home) ______Less Secure Facility ______Non-Relatives Home (informal) ______Corrections Center ______Adoptive Home (foster child prior) ______Residential Placement ______Regular Foster Home ______Psychiatric hospital ______Therapeutic Foster Home ______Temporary / Emergency Shelter ______Group Home ______Unknown

PARENT / LEGAL GUARDIAN NAME DATE OF RELATIONSHIP TO CHILD M/F BIRTH Marital Status of parent(s) of guardian(s): ______

Ethnicity of Family: ______

Is the identified child/children living with the parent/legal guardian? _____Yes _____ No

If child/children is not living with parent/legal guardian, with whom are they living? ______

______

If child’s address is different than parent/legal guardian, please list:

Address: ______

City: ______State: ______Zip: ______

Home Phone: ______Work Phone: ______

Cell Phone: ______Pager: ______

If the family does not have a phone, is there a number where we can leave messages: ___No ___Yes

If yes, the telephone number: ______

OTHERS LIVING IN THE FAMILY

NAME DATE OF BIRTH M/F LIVING AT HOME

Has the child(ren) been placed out of the home before? _____No _____ Yes If yes, please list all placements:

NAME OF CHILD NAME OF FACILITY CONTACT / ADDRESS / PHONE DATES TO / FROM

1. Please describe the events that led up to this referral: ______

______

2. Please describe any family history that relates to present events: ______

______

3. Please describe the child’s legal history, if any (probation status, criminal charges, etc.): ______

______

4. Please list problems that you believe contribute to the situation (e.g. substance abuse, truancy, etc.):

______

______5. Please list the strengths of the family: ______

______

6. What changes does the family have to make in order for the child(ren) to remain in the home: ______

______

7. Please explain any safety issues that may impact our work with the family: ______

______

______8. What services does the family receive (please check all that apply):

___ CPS ___ Big Brothers / Sisters / Mentor ___ Department of Social Services ___ Court Based Services (Probation) ___ Family Counseling / Therapy ___ Outpatient Counseling / Psychotherapy ___ Special Education ___ Inpatient Psychiatric Treatment ___ Foster Care ___ Day Treatment ___Group Home ___ Alcohol or Drug Treatment ___ Runaway Support Program ___ Self-Help or Support Group (AA) ___ Psycho Educational Group ___ Residential Treatment ___ Other

______(Signature of person taking Referral information) (Date)