Strong Mothers & Early Childhood Mental Health (0-5) Referral Form
For questions or concerns, call 718-263-0740 ext. 650
Date
*
-
Month
-
Day
Year
Date
Client Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Language
*
Please Select
English
Spanish
Bilingual (English/Spanish)
Bilingual (English/Other)
*Services are provided in English and Spanish.
Is parent able to participate in Zoom video calls?
*
Yes
No
Are services mandated?
*
Yes
No
Is parent pregnant?
*
Yes
No
Please list the full name, age, and gender of the child(ren) that this parent has.
Number of Children
*
Child #1
*
Full Name
Date of birth
Gender
*
Male
Female
Child #2
Full Name
Date of Birth
Gender
Male
Female
Child #3
Full Name
Date of Birth
Gender
Male
Female
Child #4
Full Name
Date of birth
Gender
Male
Female
Child #5
Full Name
Date of birth
Gender
Male
Female
Does parent have custody of their child(ren)?
*
Yes
No
If no, does parent have visits with their child(ren)?
*
Yes
No
N/A
Are there any Order of Protections in Place?
*
Please Select
Yes, Full OOP
Yes, Limited OOP
No
Unknown
If yes, please specify who the Order of Protection against:
Please read the following terms and condition when responding to the questions below:
Please note that any confidential information provided to us on the party referred should be authorized in writing by the party prior to release of information
Child(ren)'s clinical diagnosis:
*
If no diagnosis type N/A.
Are there concerns involving the parent's use of substances?
*
Yes
No
If yes, please note that parent's with substance use concerns must be enrolled in a substance abuse program and be practicing sobriety for a minimum of two months before they are able to participate in our program. Please include a short summary of the steps being taken to address the substance use concern:
*
Type N/A if substance use does not apply to parent.
Parent's Clinical Diagnosis:
*
Please list all mental health and physical conditions here.
If parent has a clinical diagnosis, are they compliant with their medication treatment plan?
*
Please Select
Yes, parent is compliant.
No, parent is not compliant.
Parent is not prescribed medication/does not have a clinical diagnosis.
Unknown
If parent is involved in clinical treatment, please include the name of the treatment center or doctor providing services, and their contact information.
Treatment Center/ Doctor Providing Services
Phone Number/ Email
Forestdale STAFF ONLY - Is the client receiving services for EFFC?
*
Yes
No
Is the foster parent in OSI?
*
YES
NO
Parent not in foster care
Click on the link to view service description
https://form.jotform.com/242627631303046
Please Select the Individual and Group Services Being Requested
Services are offered in English and Spanish
Requesting Individual Services
Case Planning/Advocacy
Individual Therapy
Parenting Support (Community and Connection)
Doula: Breastfeeding/
Pregnancy/Newborn Support
Attachment and Biobehavioral Catch-Up
CPP (INTERNAL USE ONLY)
Individual Services
Requesting Group Services
Parenting Skills (10 wks)
Circle of Security Parenting (8-10 weeks)
Anger Management (10 wks)
Domestic Violence (10 wks)
Domestic Violence: A Window to Healing (12 wks)
Group Services
Why is this parent being referred for these services?
*
Please provide a summary of the client's ACS case. Help us understand the reasoning the client needs to take the services. Because it is COURT MANDATED, is not a valid reasoning. Please specify the type of abuse if any. (i.e. neglect (educational/medical/lack of supervision? corporal punishment? sexual abuse?)
Client Availability (check all that apply!)
*
Morning (10AM-1PM)
Afternoon (2pm-5pm)
Evening (4pm-7pm)
Virtual
In-Person
Is parent currently engaged in other services not with Strong Mothers (Mental Health, Substance Abuse, Psychiatric, etc...)?
*
Please specify.
Referral Agency Information
Referring Staff Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Supervisor's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please select your organization:
*
ACS
Forestdale Foster Care
Other Foster Care
Forestdale Preventive
Other Preventive
Community Based Organization
Law Office
University Settlement
Self Referred
Other
Please upload Order of Protections if any (full/temporary):
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of
Please upload the petition for this parent
*
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of
Please upload the HIPPA form with the parents signature/date stamped:
*
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of
Please upload the OSI document in the referral (if applicable)*
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of
Submit
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