Family Mentoring Referral Form

Contact Info

Contact information for the person referring a child(ren) 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

Funding Status

Date of Approval or Anticipated Approval

Hours Approved or Requested

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

Maximum upload size: 516MB

FAPT Funded Child

Is the child in foster care?

Yes

No

Name *

Date of birth

Race/ Ethnicity

Gender

Current School & Grade

Religious Affiliation

Preferred Language

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

Preferred Language

Current Address

Availability to Meet with a Family Mentor

Biological Father

Will the Biological Father be a service recipient?

Yes (complete fields below)

No

Name

Age

Race/Ethnicity

Employer

Phone

Email

Religious Affiliation

Preferred Language

Current Address

Availability to Meet with a Family Mentor

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

Preferred Language

Current Address

Availability to Meet with a Family Mentor

Additional Client Information

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 (attach copy below)

No

Safety Plan Upload

Maximum upload size: 516MB

Court Involvement (attach court order below if available)

None

Supervision

Supervision & Protection

Protection order in place

Pending Court Hearing: (include date & time)Pending Court Hearing: (include date & time)

Court Order Upload

Maximum upload size: 516MB

Please indicate the areas of critical concern:

Substantial Risk of Injury/Environment Injurious to Health and Welfare

Parent’s negative physical interaction with child is excessive

Interaction between parents presents risk of harm to child

Parent’s negative language is excessive and positive interaction is deficient

Interaction between siblings presents risk of harm to child

Inadequate Supervision

Parent is unable/unwilling to provide appropriate supervision for child

Inadequate Shelter/ Environmental Neglect

Residence is structurally unsafe

Residence has safety hazards (e.g., electrical)

Residence is unsafe and/or insufficient heat

Water and toilet facilities in residence are inadequate

Unsanitary conditions exist in residence

Residence has insufficient space and furniture

Inadequate Food/ Malnutrition/ Failure to Thrive

Parent fails to obtain adequate food for child

Parent fails to prepare and serve adequate food

Parent serves unclean/ spoiled food

Inadequate preparation of infant formula/food

Inadequate food preparation equipment

Food storage hygiene

Medical Neglect

Child’s personal hygiene is inadequate

Parent’s personal hygiene is inadequate

Child’s dental care is inadequate

Parent fails to immunize child

Parent fails to obtain essential medical appointments for child

Parent lacks competence in routine and emergency medical care for child

Parent fails to secure special education/mental health services

Inadequate Clothing

Child’s clothing is insufficient and/or unclean

Exploitation/ Sexual Abuse

Parent fails to protect child from physical harm or sexual exploitation

Parent sexually exploits or allows others to exploit child

Abandonment/ Lock-Out

Parent refuses to shelter child(ren)

Parent locks child out of residence

Synopsis of Relevant History

Briefly state the PRIMARY PRESENTING CONCERN(s)

At least 1 concern is required. List up to 3.

Priority Area(s) for Improvement:

Family’s Presenting Strengths:

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

Suicide or self-harm behaviors (if a safety plan is in place, please send a copy)

Ongoing domestic violence

Inappropriate use of weapons

Sexual abuse

Sexual offender living in the home

Gang involvement

Ongoing lice or bed bug infestation

Unsafe pets

Active substance use

Additional Comments

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Family Mentoring Referral Form