Scott County Family Resource Center

Ninth Grade Youth Services Center Toni Knight, Coordinator 502-863-4635 ext 4577

REFERRAL FORM

Referral Date______

Student’s Name______Last First Middle Sex______DOB/Age______Social Security #______

Parent’s Name______(Father/Mother/Legal Guardian) Home Address______Street/Road City State Zip Mailing Address (if different from home address)______Street/Road/PO Box + Number ______City State Zip Home Phone______Work #______Cell #______

Contact Phone______Contact Name______

Referred by: ______Self Parent Name Agency School Staff/Teacher

Has the Child/Family been referred to any other agency? Yes No If so, which agency? ______

Child/Family Needs (please check all that apply)

Child Care Health Basic Needs Infant Care Health Education Employment/Training Preschool TB Test Utilities After School Care Hearing/Speech Housing Summer Camp Dental Appliance Child Care Provider Training Head/Scalp Food  Health Insurance Transportation Family Literacy Vision/Glasses Clothing Child Development Immunizations Furniture PAT Referral Hygiene Holiday Assistance Adult Education Illness Drop Out Risk (specify Doctor Referral Physical

Educational Support Families in Training Other School Supplies Teen Parent Mental Health Needs Truancy Adoption/Foster Care Peer Relationships Behavior Problems Pregnancy Marital Relationships Special Needs Services New Parent Death/Grieving Respite Care Parenting Programs Mentoring Program Disability

COMMENTS:

ALL INFORMATION IS CONFIDENTIAL