Family Advocacy Initiative

Santa Clara County Social Services Agency Department of Family and Children’s Services PARENT ADVOCATE REFERRAL

Date of Referral:

Referral Source: Case Type: Self-Referral FM DI Social Worker FR VFR TDM Facilitator IS VFM

Time of TDM: Date: Location: Case Name: Case #: Social Worker: Name SW #: Telephone PARENTS To be completed by Social Worker: Please check the box next to the name of the parent you are referring. **If you are referring both parents, can they be served by one advocate? Yes No

Name Name

Street Street

City and ZIP Code City and ZIP Code

Telephone Number(s) Telephone Number(s)

Ethnicity and Language Ethnicity and Language Yes No Yes No Disability If yes, please specify Disability If yes, please specify

Child(ren) Name DOB

Name DOB Name DOB

Name DOB Name DOB Summary of Reason for DFCS Intervention

Special Circumstances/Comments

FOR ARCC USE ONLY: Email request to: Ayanna Vanderbilt Date Received: ______Email: [email protected] Staff Assigned: ______Phone: (408) 793-8817 Date Assigned: ______

SCZ 189.doc File: 6th Fastener, Right- - Middle Parent Advocate Referral – rev.4/8/18 Page 1 of 2