Resource Center Referral Form

Together For Families

Resource Center Referral Form
*The referral form is for Cobb and Bartow County DFCS, Court employees, and Advocates internal referrals only, for new clients. Established clients can contact us directly at 470-814-2109

Referrals can be made for families receiving Family Preservation Services, Post-Reunification, and Relative Caregivers when poverty is a barrier to making or maintaining a placement. Families may receive supplies from the resource center quarterly for 12 months from the time of the referral as long as the children are in the home.

Children must be in the home of the Primary Caregiver (PCG).
REFERRAL SOURCE: *

DFCS COURT INTERNAL (Advocates for Children)
COUNTY: *

COBB BARTOW
REFERRER'S NAME: *

First Name Last Name
REFERRER'S TITLE: *
REFERRER'S EMAIL: *
example@example.com
BEST NUMBER TO REACH REFERRER: *
Please enter a valid phone number.
HAS FAMILY AGREED TO BE REFERRED: *
If you answered "NO," please do not submit this referral.
PRIMARY CAREGIVER
Name: *

First Name Last Name
Relationship to Children: *
Race:
Gender:
Phone Number *
Please enter a valid phone number.
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
CHILDREN:
Number of Children in the Care of the Primary Caregiver: *
Number Currently in Your Care
Please Indicate the tangible needs of children and family: *
Please indicate if you are able to pick up the items from our Resource Center, or if you would like for us to arrange pick-up, or drop-off with Client. *

I will pick up items at the Resource Center (1301 Shiloh Road NW, Unit 850 Kennesaw, GA 30144). Call week days between 9-5 to schedule a day and time: 470-814-2109. Requesting for Together for Families to arrange with Client pick-up or drop-off items (Clients who pick up items are provided with a one time $25 gas card).
Referring Worker's Signature: *

Clear
Today's Date: *

Month Day Year
Date
Should be Empty:

Together For Families

PRIMARY CAREGIVER

CHILDREN: