Strong Mothers Referral Form

Strong Mothers & Early Childhood Mental Health (0-5) Referral Form

For questions or concerns, call 718-263-0740 ext. 650
Date*

MonthDayYear
Date
Client Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Language *
*Services are provided in English and Spanish.
Is parent able to participate in Zoom video calls?*

YesNo
Are services mandated?*

YesNo
Is parent pregnant?*

YesNo
Please list the full name, age, and gender of the child(ren) that this parent has.
Number of Children*
Child #1*

First NameLast Name
Child #1 Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Child #2

First NameLast Name
Child #2 Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Child #3

First NameLast Name
Child #3 Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Child #4

First NameLast Name
Child #4 Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Child #5

First NameLast Name
Child #5 Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Does parent have custody of their child(ren)?*

YesNo
If no, does parent have visits with their child(ren)?*

YesNoN/A
Are there any Order of Protections in Place?*
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?*

YesNo
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?*
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 ServicesPhone Number/ Email
Forestdale STAFF ONLY - Is the client receiving services for EFFC?*

YesNo
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

Rows	Case Planning/Advocacy	Individual Therapy	Parenting Support (Community and Connection)	Doula: Breastfeeding/ Pregnancy/Newborn Support	Attachment and Biobehavioral Catch-Up	CPP (INTERNAL USE ONLY)	Co-parenting
Individual Services

Requesting Group Services

Rows	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)Evening (6pm-8pm)VirtualIn-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 NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Supervisor's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Please select your organization:*

ACSForestdale Foster CareOther Foster CareForestdale PreventiveOther PreventiveCommunity Based OrganizationLaw OfficeUniversity SettlementSelf ReferredOther
Please upload Order of Protections if any (full/temporary):

Cancelof
Please upload the petition for this parent*

Cancelof
Please upload the HIPPA form with the parents signature/date stamped:*

Cancelof
Please upload the OSI document in the referral (if applicable)*

Cancelof
Should be Empty:

Strong Mothers & Early Childhood Mental Health (0-5) Referral Form

Client Information

Please list the full name, age, and gender of the child(ren) that this parent has.

Please read the following terms and condition when responding to the questions below:

Please Select the Individual and Group Services Being Requested

Referral Agency Information