<p> 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]</p><p>Date of Referral: ______</p><p>Name of Referring Worker______</p><p>Agency: ______</p><p>Phone Number______Fax Number: ______</p><p>Address: ______</p><p>County: ______City: ______State: ______Zip: ______</p><p>Is the case Medicaid? yes _____ No If yes, please give Medicaid #:______</p><p>Has the family been approved by FAPT/CAT? _____Yes _____No</p><p>Will this be mandated or non-mandated funds? ______</p><p>How many hours have been approved? ______</p><p>What services were approved? </p><p>_____ Home-based _____ Outpatient Therapy _____ Mentoring</p><p>_____ Behavior Management (BCBA/LBA) ____ Behavior Management (ABA Specialist) </p><p>_____ Out of home respite _____ Supervised Visitation ____ In-home respite</p><p>Has the family been informed that you are referring them to Family Partners? ____Yes ____No FAMILY</p><p>Family Name: ______</p><p>Address where child is currently living: ______</p><p>County: ______City: ______State:______Zip:______</p><p>Telephone Number: ______</p><p>IDENTIFIED DATE OF M/F SOCIAL SECURITY CHILD’S/CHILDREN’S BIRTH NUMBER NAME</p><p>Where is the child(ren) living now?: (please check one)</p><p>______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</p><p>PARENT / LEGAL GUARDIAN NAME DATE OF RELATIONSHIP TO CHILD M/F BIRTH Marital Status of parent(s) of guardian(s): ______</p><p>Ethnicity of Family: ______</p><p>Is the identified child/children living with the parent/legal guardian? _____Yes _____ No</p><p>If child/children is not living with parent/legal guardian, with whom are they living? ______</p><p>______</p><p>If child’s address is different than parent/legal guardian, please list:</p><p>Address: ______</p><p>City: ______State: ______Zip: ______</p><p>Home Phone: ______Work Phone: ______</p><p>Cell Phone: ______Pager: ______</p><p>If the family does not have a phone, is there a number where we can leave messages: ___No ___Yes</p><p>If yes, the telephone number: ______</p><p>OTHERS LIVING IN THE FAMILY</p><p>NAME DATE OF BIRTH M/F LIVING AT HOME</p><p>Has the child(ren) been placed out of the home before? _____No _____ Yes If yes, please list all placements:</p><p>NAME OF CHILD NAME OF FACILITY CONTACT / ADDRESS / PHONE DATES TO / FROM</p><p>1. Please describe the events that led up to this referral: ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>2. Please describe any family history that relates to present events: ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>3. Please describe the child’s legal history, if any (probation status, criminal charges, etc.): ______</p><p>______</p><p>______</p><p>______</p><p>4. Please list problems that you believe contribute to the situation (e.g. substance abuse, truancy, etc.):</p><p>______</p><p>______</p><p>______</p><p>______5. Please list the strengths of the family: ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>6. What changes does the family have to make in order for the child(ren) to remain in the home: ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>7. Please explain any safety issues that may impact our work with the family: ______</p><p>______</p><p>______</p><p>______</p><p>______8. What services does the family receive (please check all that apply):</p><p>___ 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</p><p>______(Signature of person taking Referral information) (Date)</p>