Over 50 Years Providing Solutions . . .
When Children & Families Need Them Most
Supervised VisitationCenter
REFERRAL FORM
______
This referral is for: ___ PARENTING CLASSES (Parenting Program) ___ SUPERVISED VISITS (Dependency Program)
Today’s Date: ______Case Name: ______
Date of Detention: ______Case Status: ___Pre-Disposition ___Post-Disposition
Caseworker Name: ______Agency: ______
Caseworker’s Number: ______Alternate Number: ______
Caseworker’s e-mail address: ______
County the court case belongs to: ______GAL if appointed: ______
PARTICIPANT INFORMATION:
Name: ______Relationship: ___MOTHER ___FATHER ___Other: ______
Address: ______
Phone: ______Alternate Phone: (Cell, Work, Pager): ______SSN: ______
DOB: ______Gender: ______Race: ______Marital Status: ______
Name: ______Relationship: ___MOTHER ___FATHER ___Other: ______
Address: ______
Phone: ______Alternate Phone: (Cell, Work, Pager): ______SSN: ______
DOB: ______Gender: ______Race: ______Marital Status: ______
Name: ______Relationship: ___MOTHER ___FATHER ___Other: ______
Address: ______
Phone: ______Alternate Phone: (Cell, Work, Pager): ______SSN: ______
DOB: ______Gender: ______Race: ______Marital Status: ______
CHILD(REN) INFORMATION:
Name: ______SSN:______DOB: ______
Gender: ______Race: ______In DCF Custody? _____Yes _____No ______PS _____FC _____ESC
Name: ______SSN:______DOB: ______
Gender: ______Race: ______In DCF Custody? _____Yes _____No ______PS _____FC _____ESC
Name: ______SSN:______DOB: ______
Gender: ______Race: ______In DCF Custody? _____Yes _____No ______PS _____FC _____ESC
Name: ______SSN:______DOB: ______
Gender: ______Race: ______In DCF Custody? _____Yes _____No ______PS _____FC _____ESC
CURRENT PLACEMENT/CARETAKER INFORMATION:
Name: ______Relationship: ______FC Licensed? ______
Address: ______
Phone: ______Alternate Number: (Cell, Work, Pager): ______
HISTORY OF CASE: (Must be completed)
Alleged Perpetrator:______Relationship to child:______
Alleged Perpetrator:______Relationship to child:______
TYPE OF ABUSE: (Please check all that apply)
___Abandonment ___Alcohol ___Emotional Abuse ____ Medical Neglect ____Neglect ___Physical Abuse ___Sexual Abuse ___Substance Abuse (Type: ______
BRIEF NARRATIVE OF SITUATION THAT CAUSED THIS REFERRAL TO BE MADE:
______
______
______
______
Pertinent PSYCHOLOGICAL or MEDICAL Information that staff should be aware of to ensure a safe and comfortable experience at the ChildGuidanceCenterSupervisedVisitationCenter.
______
______
**INCOMPLETE REFERRALS WILL NOT BE PROCESSED.
LOCATION INFORMATION: DAY & TIME PERFERRED:
6316 SAN JUAN AVENUE (serving Westside) 1. ______
1110 EDGEWOOD AVENUE (serving Northside, Eastside & NassauCounty) 2.______
1100 CESERY BLVD., STE. 100 (serving Arlington, Southside & Beaches) 3.______
Visits from ___/___/____ through ___/___/____ *Resubmit new form after 6 months for continuation of visits.
Please fax Referral to:
FAX (904) 745-3086
If you have questions or concerns regarding either of these programs, please call 745-3070 x326.