Triple P Program Referral Form

Referral Source*

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

Name of Agency (if referred by agency)

Name of worker (if referred by agency)

First NameLast Name

Email for worker (if referred by agency)*

example@example.com

Parent/caregiver(s) name*

First NameLast Name

Phone number for worker (if referred by agency)

Area CodePhone Number

Parent's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/caregiver(s) ethnic origin*

Parent/caregiver(s) home phone number

Area CodePhone Number

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

Area CodePhone 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 NameLast Name

Child's date of birth*

Date

What school does this child currently attend?*

Ages of any other child(ren) in the home listed abve*

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.The self-paced 10-week,online Triple P program (Not all parents suitable. Please note that a Triple P recommendation will be based on the information received).

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)*

Does this referral involve any family/domestic violence (reported to law enforcement or not), and do you know if a Risk Assessment was completed with the family?*

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.*

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 (Positive Parenting program)/ referral form