Defiance County Family & Children First by 41lKA2OV


									                                Coshocton County Family & Children First
                                           Creative Options
                              REFERRAL FOR SERVICE COORDINATION

Family Name                           Date

School District                                                   Placement/Grade

Mother’s/Custodian Name               Custody       yes     no


Phone                                  Employment

Father’s/Custodian Name                Custody       yes     no


Phone                         Employment

Foster Placement       yes   no       Relative      yes     no            Permanent    yes     no

Referring Professional

Agency                                                            Phone

                                   CURRENT AGENCY INVOLVEMENT
                                         (Check all that apply)

   Thompkins                                 Ridgewood Schools                         City Health Dept.
   CBHC                                      River View Schools                        First Step
   Juvenile Court                            Opportunity School                        Family PACT
   DJFS                                      Church/Religious Involvement              Big Brothers/Big Sisters
   MRDD                                      DYS                                       Head Start
   Help Me Grow                              Six County                                Other
   Coshocton City Schools                    County Health Dept.

                                    RECOMMENDED TEAM MEMBERS

What are the goals/outcomes that the family wants to achieve?
Short Term (60 days):
Long Term (6 months):

Is at least one parent/custodian willing to be on the integrated services team?       yes     no

                  Please submit completed form with Release of Information to FCFC office.
Updated 03-2009

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