Carolina Family Services
“Because ALL Families Matter”
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In Home Family Services Referral Form
To make a referral for Intensive Family Services, fill out the form below, and click the Send button.
Case Manager/Referral Agent's Name:
Case Manager/Referral Agent's Address:
Case Manager/Referral Agent's Phone:
Case Manager/Referral Agent's Email:
Who should be contacted with the results of this referral?
Have you informed the family you are making this referral?
Yes
No
If so, what was the family's response?
Identified Child's First Name:
Identified Child's Middle Name:
Identified Child's Last Name:
Identified Child's Date of Birth:
Identified Child's Social Security #:
Identified Child's Medicaid #:
Identified Child's School:
Does this child live at home?
Yes
No
If not, where and with whom is the child currently living?
Number and Ages of Siblings:
Parent or Legal Guardian First Name:
Parent or Legal Guardian Middle Name:
Parent or Legal Guardian Last Name:
Caretaker's Address:
Caretaker's Phone:
Service(s) Requested:
(Ctrl or Cmd click to
select multiple items)
Comprehensive Assessment
Individual Therapy
Family Therapy
Crisis Management
Service Plan Development
Behavior Modification
RPS
Family Support
Please check any of the following that are of concern and are part of the reason for this referral:
Imminent Risk of Out of Home Placement for Child
Problems with Peers
Preparation for Family Reunification Within Last Few Weeks of Out-of-Home Placement
Possible Sexual Abuse
Academic Difficulty
Lack of Social Skills
Possible Drug/Alcohol Use by Child
Teenage Pregnancy
Family in Need of Parenting Education
Grief/Loss Issues
Domestic Violence
Substance/Alcohol Abuse in Family
Other, Please Explain:
What Other Services/Agencies are currently being used or have been used in the past and to address what issue?
Is the Child/Parent currently on medication?
Yes
No
Medication and Dosages:
Does the child have any educational, physical or mental health diagnoses?
Yes
No
If yes, please indicate what the diagnosis is:
What would you identify as the child's or family's strengths?
Are there any safety concerns that the CFS Counselor should know about when providing in-home family services? (dogs, guns, family history of violence, etc.)
Form Completed By:
Date: