Triple P Program Referral Form

Referral Source *

I am a parent/caregiver in need of services I am a professional contacting you to refer a parent/caregiver to services

Name of Agency (if referred by agency)

Name of worker (if referred by agency)

First Name Last Name

Email for worker (if referred by agency) *

example@example.com

Phone number for worker (if referred by agency)

Area Code Phone Number

Parent/caregiver(s) name *

First Name Last Name

Parent's address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Parent/caregiver(s) ethnic origin *

African American/Black Caucasian/White Asian/Pacific Islander Hispanic/Latinx Bi-Racial Other Prefer not to answer

Parent/caregiver(s) home phone number

Area Code Phone Number

Parent/caregiver(s) cell number (that accepts voicemail) *

Area Code Phone Number

Parent/caregivers date of birth: *

Date

Parent/caregiver(s) email address *

example@example.com

County parent/caregiver(s) lives in *

Parent/caregiver(s) primary language *

Identified child's name *

First Name Last Name

Child's date of birth *

Date

I’d like an organization/practitioner to refer the above listed parent/caregiver to the following Triple P level(s). Please note, if you are referring from an agency/organization, we kindly ask that you inform the parent/caregiver what Triple P level(s) they're being referred to: *

Seminar: Available for parents of children from birth to 12 years. In Greenville County, Triple P Level 2 is delivered as a Selected Seminar Series – an introduction to the strategies of positive parenting and Triple P. Parents attend any number of three 90-minute seminars ("Power of Positive Parenting"; "Raising Confident, Competent Children"; and "Raising Resilient Children"). Take-home tip sheets are given to all parents who attend Triple P seminars. Primary Care Triple P – A brief face-to-face or telephone intervention with a provider (from areas such as child and community health, education, allied health, child care etc.). Approximately four individual consultations lasting between 15 and 30 minutes. Uses tip sheets and Positive Parenting Booklet to reinforce strategies. Discussion Groups – Two-hour small group sessions, targeting a specific problem behavior or issue. Each discussion group can be taken as a stand-alone session or as part of a series. There are four topics for parents of children 0 –12 (Dealing with disobedience; Managing fighting and aggression; Developing good bedtime routines; and Hassle-free shopping with children). Standard: Level 4 is for parents of children with severe behavioral difficulties or in the case of Group Triple P, for motivated parents interested in gaining a more in-depth understanding of Positive Parenting. It is available for parents of children from birth to 12 years and covers Triple P's 17 core positive parenting skills that can be adapted to a wide range of parenting situations. Group Triple P – Groups of no more than 12 parents attend five sessions and are supported with three phone counseling/catch-up sessions at home. Uses DVDs and workbook to engage parents and reinforce strategies.

Primary concern: Please provide us with as much information as possible about your current concerns regarding the child/family's health and well-being: *

Please give details of any service/agency interventions to date (for the parent/caregiver) *

I hereby certify that proper notification of Triple P services has been discussed with the parent/guardian and consent has been given for the exchange and release of information for this purpose, if applicable. *

Clear

Thank you for taking the time to complete the Triple P Referral Form. The referral will be reviewed asap.

Someone from a local Triple P service-delivery organization will contact you.

Please click submit.

Triple P-Greenville (Positive Parenting program) referral form