Community Uplift - Referral Form

Date

County of Origin *

Douglas

Klamath

Lake

Other

If County of Origin is other, please specify

Parent/Guardian Contact Information

Parent/Guardian/Client Name

Is client an unaccompanied minor? *

Yes

No

Parent/Guardian/Client Date of Birth

Parent/Guardian/Client Relationship to Child/Client

Mother

Father

Grandparent

Aunt/Uncle

Foster Parent

Self

Other

Parent/Guardian/Client Contact Phone Number - Numbers Only: cannot contain dashes, slashes nor spaces (ex: 5415551234)

Parent/Guardian/Client Type of Phone

If Parent/Guardian/Client type of phone is other, please specify

Parent/Guardian/Client Additional Contact Phone Number - Numbers Only: cannot contain dashes, slashes nor spaces (ex: 5415551234)

Parent/Guardian/Client Type of Additional Phone

If Parent/Guardian/Client type of additional phone is other, please specify

Parent/Guardian/Client Phone contact options

Call

Leave message

Text messaging

DO NOT LEAVE MESSAGE OR TEXT

Parent/Guardian/Client E-mail

Parent/Guardian/Client Mailing Address

Parent/Guardian/Client City

Parent/Guardian/Client State

Parent/Guardian/Client Zip Code

Parent/Guardian/Client's Primary Language

If Parent/Guardian/Client's primary language is other, please specify

Would you like to list a 2nd Parent/Guardian/Client?

2nd Parent/Guardian/Client Name

2nd Parent/Guardian/Client Date of Birth

2nd Parent/Guardian/Client Relationship to Child/Client

Mother

Father

Grandparent

Aunt/Uncle

Foster Parent

Spouse/Partner

Other

If 2nd Parent/Guardian/Client relationship to child/client is other, please specify

2nd Parent/Guardian/Client Contact Phone Number - Numbers Only: cannot contain dashes, slashes nor spaces (ex: 5415551234)

2nd Parent/Guardian/Client Type of Phone

If 2nd Parent/Guardian/Client type of phone is other, please specify

2nd Parent/Guardian/Client Phone contact options

Call

Leave message

Text messaging

2nd Parent/Guardian/Client E-mail

2nd Parent/Guardian/Client's Primary Language

If 2nd Parent/Guardian/Client's primary language is other, please specify

Expecting Mother Information:

Are you or your partner Expecting?

Yes

No

Expecting/Pregnant Mother Due Date

Does expecting/pregnant mother have a primary care provider (PCP)?

Yes

No

Primary Care Provider (PCP) Information

Is there currently a child/ren living in the home?

Yes

No

Child/Client

Name of Child/Client #1

Child #1 Date of Birth

Is Child #1 less than 2 years of age?

Yes

No

Child #1 Age Months

Child #1 Age Years

Child #1 Gender

If Child #1 Gender is X and you wish to specify further, please list here

Child #1 Primary Language

If Child #1 Primary Language is other, please specify

Child/Client #1 Relationship to Parent/Guardian

If Child/Client #1 Relationship to Parent/Guardian is other, please specify

Is there a second child in the household?

Child/Client #2

Name of Child/Client #2

Child #2 Date of Birth

Is Child #2 less than 2 years of age?

Yes

No

Child #2 Age Months

Child #2 Age Years

Child #2 Gender

If Child #2 Gender is X and you wish to specify further, please list here

Child #2 Primary Language

If Child #2 Primary Language is other, please specify

Child/Client #2 Relationship to Parent/Guardian

If Child/Client #2 Relationship to Parent/Guardian is other, please specify

Is there a third child in the household?

Child/Client #3

Name of Child/Client #3

Child #3 Date of Birth

Is Child #3 less than 2 years of age?

Yes

No

Child #3 Age Months

Child #3 Age Years

Child #3 Gender

If Child #3 Gender is X and you wish to specify further, please list here

Child #3 Primary Language

If Child #3 Primary Language is other, please specify

Child/Client #3 Relationship to Parent/Guardian

If Child/Client #3 Relationship to Parent/Guardian is other, please specify

Is there a fourth child in the household?

Child/Client #4

Name of Child/Client #4

Child #4 Date of Birth

Is Child #4 less than 2 years of age?

Yes

No

Child #4 Age Months

Child #4 Age Years

Child #4 Gender

If Child #4 Gender is X and you wish to specify further, please list here

Child #4 Primary Language

If Child #4 Primary Language is other, please specify

Child/Client #4 Relationship to Parent/Guardian

If Child/Client #4 Relationship to Parent/Guardian is other, please specify

Is there a fifth child in the household?

Child/Client #5

Name of Child/Client #5

Child #5 Date of Birth

Is Child #5 less than 2 years of age?

Yes

No

Child #5 Age Months

Child #5 Age Years

Child #5 Gender

If Child #5 Gender is X and you wish to specify further, please list here

Child #5 Primary Language

If Child #5 Primary Language is other, please specify

Child/Client #5 Relationship to Parent/Guardian

If Child/Client #5 Relationship to Parent/Guardian is other, please specify

Current Needs

Please check all current needs that apply:

Medical Condition

Teen Parent

Parent with Learning Disability

Child with/at risk for Developmental Delay/Disability

Infant Feeding/Weight Loss or Gain Problem

Risk of Maternal Depression

Isolation/Lack of Support

Child Behavior Concerns

Domestic Violence (past history)

Domestic Violence (present)

Limited Income/Resources

Wants additional Parenting Resources

Other

If current need is other, please specify

Medical Condition(s) please list:

Programs Currently Connected With

Current Programs Connected With

WIC

Healthy Families

Family Development Center (Douglas)

Family Relief Nursery (Douglas)

Healthy Start (Douglas)

Early Head Start

Head Start

Early Intervention (EI)

Early Childhood Special Education (ECSE)

Babies First

CaCoon

Maternity Nurse Case Management

OHP

Child Welfare

Self Sufficiency

TANF/JOBS

SNAP

ERDC

New Day ( Douglas)

New Beginnings ( Douglas)

Family Gathering Place ( Klamath)

Please Add Additional Information If Desired

Parent(s)/guardian(s) is/are aware this referral is being made.

Yes

No

Individual filling out this application

I am filling this out for myself or family (listed on this application)

I am filling this out on behalf of those listed above

My signature authorizes the provider, taking this initial referral, to provide my name and contact information to service providers working in partnership with Community UPLiFT (please type full name).

This authorization expires on (not to exceed one year from the date of signature)

Agency/Organization

Agency/Organization - Other

Agency/Organization Contact Person Name

Agency/Organization Phone Number - Numbers Only: cannot contain dashes, slashes nor spaces (ex: 5415551234)

Agency/Organization Contact E-mail Address

Agency/Organization Fax Number - Numbers Only: cannot contain dashes, slashes nor spaces (ex: 5415551234)

ROI - Release of Information Upload

Community Uplift - Referral Form

Parent/Guardian Contact Information

Expecting Mother Information:

Child/Client

Child/Client #2

Child/Client #3

Child/Client #4

Child/Client #5

Current Needs

Programs Currently Connected With

Thank you for taking the time to complete this referral application. We will be in contact soon.