Family Preservation Program Family Referral

Date of Referral:
Type of Referral:
Referring Partner Staff
First Name:
Referring Partner Staff
Last Name:
Referring Partner Staff Phone:
Referring Partner Staff Email:
Referring Agency State:
Referring Agency County:
Referring Agency Name:
Referring Agency Phone:
Referring Agency Email:
Referring Agency Address:
Referring Agency City:
Referring Agency Zip Code:
Parent(s) First Name:
Parent(s) Last Name:
Spouse/Partner First Name:
Spouse/Partner Last Name:
Family Address:
Home City:
Home State:
Home County:
Family Phone:
Family Email:
Where is the family currently living:
Name and Age of Family Members:
Please write each person's name and age on a separate line.

Community Partner & Family Questions

List any agencies the family is currently involved with, and explain how:
Is there a open DHS case?
Please describe the circumstances:
Is there concern about DHS involvement in the future?
Please Explain:
What is your reason for referring this family to our program?
Please list any risk factors that you can currently identify for family:
What are the biggest barriers for this family?
Currently, what is family's main source of income?
What is the highest level of education?
And any future Education Goals?
Do adults in the home have a solid work history?
Please Explain:
Has any adult in the home ever been incarcerated?
Please Explain:
What is the family's main mode of transportation?
Does this family have support from extended family members
(financial, emotional, other?)
What services would your family benefit from?
Please check all that apply:
Other services needed, not listed above?
Are there any behaviors or family dynamics
that should be taken into consideration?
This program requires a 12 month commitment.
Is your client ready to commit to this?
Please list anything else that you feel would be helpful
to know about the family that you are referring to our agency.

Additional Family Goals

Please list 3 short term goals you would like to work towards:
Please list 3 long term goals you would like to work towards:
This program is a year commitment,
where would you like your family to be in one year?

NOTE: At present, the Family Preservation program is generally available only in Lane County, Oregon because of budget and resource limitations. We are interested in expanding the program in cost-effective ways; if you or your organization are interested in helping, please get in touch! .