<p> Santa Clara County Social Services Agency Department of Family and Children’s Services PARENT ADVOCATE REFERRAL</p><p>Date of Referral: </p><p>Referral Source: Case Type: Self-Referral FM DI Social Worker FR VFR TDM Facilitator IS VFM</p><p>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</p><p>Name Name</p><p>Street Street</p><p>City and ZIP Code City and ZIP Code</p><p>Telephone Number(s) Telephone Number(s)</p><p>Ethnicity and Language Ethnicity and Language Yes No Yes No Disability If yes, please specify Disability If yes, please specify </p><p>Child(ren) Name DOB</p><p>Name DOB Name DOB</p><p>Name DOB Name DOB Summary of Reason for DFCS Intervention </p><p>Special Circumstances/Comments </p><p>FOR ARCC USE ONLY: Email request to: Ayanna Vanderbilt Date Received: ______Email: [email protected] Staff Assigned: ______Phone: (408) 793-8817 Date Assigned: ______</p><p>SCZ 189.doc File: 6th Fastener, Right- - Middle Parent Advocate Referral – rev.4/8/18 Page 1 of 2</p>