Coshocton County Family & Children First
REFERRAL FOR SERVICE COORDINATION
Family Name Date
School District Placement/Grade
Mother’s/Custodian Name Custody yes no
Father’s/Custodian Name Custody yes no
Foster Placement yes no Relative yes no Permanent yes no
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.