Referral Form Champaign County Family & Children First Council

Submit the online form on this page, or download, fill out and print the Referral Form.

Champaign County Referral Form
File Size:	115 kb
File Type:	docx

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Champaign County Family & Children first council referral form

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* Indicates required field

Referral Date *

Referral Source Name *

First

Last

Referral Agency Name *

Source Phone Number *

Referral Source Email *

Child's Information

Child's Name: *

First

Last

Child's DOB: *

Racial Identity: *

Child’s Gender: *

Female Male Non-binary

Child’s Ethnic Identity: *

Is the child *

living with legal guardian? in foster care? adopted? other?

If "other", please list here. *

Who has custody of the child? *

With whom is the child living? *

Primary Caretaker's Name *

First

Last

Primary Caretaker's Phone Number *

Relationship to the child: *

Type of Health Insurance (For Child): *

Name of Insurance Carrier: *

CURRENT SCHOOL INFORMATION

School District: *

School Attending: *

Current Grade: *

Are any of the following currently in place? *

IEP 504 Plan

Current system involvement

Check all that apply to child: *

Please list specific agencies for any selected. *

child's health information

If "Other", please list: *

child's behavioral health history

Other health-related issues experienced by child: *

primary caretaker(s) information

Address: *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Alternative Phone Number *

caregiver's history:

Please, complete the follow information as it pertains to child’s caregiver(s), indicating whether the behavior listed is current or historical.

Members of household

Name *

First

Last

Name *

First

Last

Name *

First

Last

Name *

First

Last

Name *

First

Last

Age *

Relationship to Child *

Describe the child’s family structure: *

Is the child currently at risk of placement outside of the home? If “yes,” please describe the risk: *

What are the strengths of the child and child’s family? *

In what ways would a multi-system team help this child/family? *

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Referral Form

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Quick Reference Guide

Phone: 937-653-4490

Email: [email protected]

Address:
1512 S US HWY 68, Suite N100
Urbana, OH 43078

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