Family Success Network Referral Form

Preliminary Screening

To be eligible for the Family Success Network of Summit County, the family must meet all of the following requirements:

1. The parent/caregiver must currently reside in Summit County.
2. The parent/caregiver must currently be responsible for at least one minor child under the age of 18 years old, or 21 years old if the child has developmental disabilities.
3. The family CANNOT have a current, active case plan with Summit County Children's Services (unless caregiver being referred is kinship/foster guardian).

At this time, does the family being referred meet all three (3) requirements indicated above?

Primary Caregiver Name

First NameLast Name

Primary Caregiver Relationship to Child(ren)

Primary Caregiver Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Best Time to Contact

Preferred Method of Contact

Primary Language Spoken in the Home

Who resides in the home (names & list if adult or child)?

Referral Source - Who is making the referral?

Other

Referrant's Name

Referent's Agency (if Service Provider)

Referent's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Referent's Email

example@example.com

Is the caregiver aware of the referral?

Would referent prefer to remain anonymous?

Child(ren) Information - Please list the names and ages of children living in the home (ex. Jane Doe - 5)

Is the caregiver currently expecting another child?

Briefly Explain the Reason for the Referral

Family Needs and Concerns (check all that apply)

Other

What services are you interested in (answer if you are the caregiver)?

Please list 3 goals that you hope to achieve while working with a Family Coach (answer if you are the caregiver).

How did you hear about the program?