Family Check Up Screening & Referral Form

The child MUST be in the home (if the child is not in the home or in long term placement, FCU is not appropriate. Please contact us for additional information.)

Child is in the home of biological parent(s)

Child is in long term foster care/kinship placement

Contact Info

Contact information for the person referring a child or children to People Places.

First Name *

Last Name *

Referral Date *

Local Department of Social Services Agency *

Contact Phone Number *

Email Address *

Enter Email

Confirm Email Address *

Confirm Email

FAPT Funding Status

Date of Approval or Anticipated Approval

Upload FAPT Funding Approval Document – in order to begin services a copy of funding paperwork needs to be received.

Maximum file size: 516MB

Child with approved funding:

Name *

Date of birth

Race/ Ethnicity

Gender

Current School & Grade

Religious Affiliation

Language Affiliation

Current Residence *

Legal Guardian

Biological Mother

Will the Biological Mother be a service recipient?

Yes (complete fields below)

No

Name

Age

Race/Ethnicity

Employer

Phone

Email

Religious Affiliation

Language Affiliation

Current Address

Availability to Meet with FCU Provider:

Biological Father

Will the Biological Father be a service recipient?

Yes (complete fields below)

No

Name

Age

Race/Ethnicity

Employer

Phone

Email

Religious Affiliation

Language Affiliation

Current Address

Availability to Meet with FCU Provider:

Identified Client’s Current Caretakers (if applicable)

Will another caretaker be a service recipient?

Yes (complete fields below)

No

Name

Age

Phone

Email

Race/Ethnicity

Employer

Religious Affiliation

Language Affiliation

Current Address

Availability to Meet with FCU provider:

Reason(s) for Referral (Please check all that apply)

Is the family receiving other social services?

Mental Health Counseling/ Substance Abuse Counseling (if yes, Provider name in blank)Mental Health Counseling/ Substance Abuse Counseling (if yes, Provider name in blank)

Special Education/ Early Intervention (if yes, Provider name in blank)Special Education/ Early Intervention (if yes, Provider name in blank)

OtherOther

Does the family have a Safety Plan?

Yes (please attach a copy)

No

Safety Plan Upload

Maximum file size: 516MB

Court involvement (if available, attach court order below)

None

Supervision

Supervision & Protection

Protection order in place

Pending court hearing (provide date & time)Pending court hearing (provide date & time)

Court Order Upload

Maximum file size: 516MB

Briefly state the PRIMARY PRESENTING CONCERN(s):

At least 1 is required. List up to 3.

Please check any that apply to the youth/family/home location where services will be provided (within the last year):

Additional Comments

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Family Check Up Screening & Referral Form