Hudson County Child Abuse Prevention Center

							                                    Hudson County Child Abuse Prevention Center
                                    586 Newark Avenue 2nd Floor Jersey City, NJ 07306
                                         Tel: (201) 798-5588 Fax: (201) 798-4242
                                                       Parenting Referral Form

Referring agency: __________________________________________________________________
Referring staff member: _________________________________________ NJS # _________________________
Office tel: ___________________________          Cell tel: _________________________________
Address: ___________________________________________________________________________
Client’s name: ________________________________________ Age: _______
Address: _____________________________________________________________Apt: __________
Telephone: home _____________________________ cell: _________________________
Is this referral court mandated: Yes: _____ No: _____ Judge/Worker: ____________________________
Describe court involvement: _______________________________________________________________________
________________________________________________________________________________________________
Is the client related to a SVU or CAC case:      ____ Yes         ____ No

History of domestic violence: ____________________________________________________________________
_____________________________________________________________________________________________
Spouse Name: _____________________________________________
Does the client have any history of mental Illness: __________________________________________________________________
_______________________________________________________________________________________________________
Is the client employed? ________                 Is the client in school? _______
Are the client’s children in the home? _______            Number of Children: ________
Please specify available time for parenting groups: _______________________________________
Please indicate if client needs childcare (if so how many children and the ages): ____________________________


Other relevant information: __________________________________________________________________
__________________________________________________________________________________________


                                           Please provide a copy of the S.A.R. with the referral.
HCCAPC reserves the right to disallow any person from participating in parenting classes if we determine that the
parenting support group is not appropriate for their needs.

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      Client’s signature                                                           Date

______________________________________________________________________________
      Referring staff signature                                                    Date

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      RDS signature                                                                Date