PCSS New Client Referral Form

PCSS Services:

Our Parent Child Specialists provide free in-home and community-based sessions to support domestic violence survivors and their children. Our services are adapted to meet the ages of your children and your family’s individual and unique needs. Families who live in the Portland metro area with at least one child aged 0-12 and are no longer in the abusive relationship qualify.
Eligibility Requirements for PCSS Services - You must be able to answer "Yes" to all 4-questions:*

1) Yes, the survivor has at least one child between the ages or 0-12 yrs. *(We serve children 0-12yrs with their parent/caregiver only.)2) Yes, the survivor & child/children can schedule their family’s sessions between 8am to 5:30pm (Tues-Fri)3) Yes, the survivor has been out of the abusive relationship for at least 3 months.4) Yes, this request is solely for counseling session; *Not for suicidal thoughts or urgent/emergent crisis; Not Court, County, or State Mandated Services. *PCSS Specialists do not attend court and will never provide family or parental fitness recommendations
*Unable to to answer "Yes" to all Requirements?

Contact 211 in your County or 1 (866) 698-6155 to learn of resources in your area
*For potential suicidal thoughts, abuse or mental health crisis Contact 911 or an appropriate agency.
- CARE NW (503) 276-9000 -or- (503) 413-2200
- Oregon Child Abuse Hotline 1-855-503-SAFE (7233)
- Suicide Hotline (800) 273-8255
- Multnomah County Mental Health Crisis Line (503) 988-4888
Services Requested:*

Counseling for a Child (*Must answer "Yes" to all 4-requirements above)Other
Contact Information
Referring Organization
Write in "Self" if you are requesting services for yourself and your child(ren).
Referring Staff Member Name

First NameLast Name
Referring Organization Phone Number
Only if known
Impact NW Counselor
If you have been working with another staff at Impact NW and know their name, please type it here.
Child's Name*
Child's Date of Birth*

MonthDayYear
Race & Ethnicity of Child *
If you prefer not to share, please write "not given".
Language(s) Spoken by Child *
Parent/Guardian's Cell Phone*
Please type 000 000-0000 if you do not have a phone number that is safe for staff to use to reach you.
Parent/Guardian Name*
Parent/Guardian Email*
example@example.com, please enter na@na.com if you do not have an email that is safe for staff to use to reach you.
Languages Spoken By Parent/Guardian *
please list any/all languages parent/guardian is comfortable using for sessions
Parent/Guardian's Zip Code
Race & Ethnicity of Parent/Guardian*
*Communication with Parent/Guardian*

Safe to call the number provided?Safe to text the number provided?Safe to email address provided?
Date Submitted*

MonthDayYear
Space is Limited

Please note, space is limited. Allow no less than 2-weeks for review. One of our staff will contact the parent/guardian for a screening call.
Preferred Counseling Appointment Days & Times

What are the best times for you to meet weekly with a counselor?

	Tuesday	Wednesday	Thursday	Friday
8am-10am
10am-12pm
12pm-2pm
2pm-4pm
4pm-6pm

Random Generated Number*
Parent/Guardian's County
Child's Date of Birth*
Revised 10/2020
STAFF ONLY SECTION: Additional Comments, Notes, Contact Dates/Times
Should be Empty:

PCSS Services:

*Unable to to answer "Yes" to all Requirements?

Contact Information

Space is Limited

Preferred Counseling Appointment Days & Times