Resource Center Referral Form

Together For Families

Resource Center Referral Form
*The referral form is for Cobb and Bartow County DFCS, Court (FTC, GAL, or Parent Attorney) for new clients. Established clients can contact us directly at 470-814-2109

Referrals can be made for families struggling with poverty and receiving Family Preservation Services, Post-Reunification, and Relative Caregivers when poverty is a barrier to making or maintaining a placement.

Children MUST be in the home and care of the Primary Caregiver (PCG) being referred!
REFERRAL SOURCE:*

DFCSCOURT (FTC, GAL, CASA, or Parent Attorney)Advocates Internal
COUNTY:*

COBBBARTOW
REFERRER'S NAME:*

First NameLast 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 NameLast Name
Date of Birth*

MonthDayYear
Date
Relationship to Children:*
Gender:*
Best Phone Number*
Please enter a valid phone number.
Email
example@example.com
Language spoken in the home*
English, Spanish, etc…
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CHILDREN:
Number of Minor Children in the Care of the Primary Caregiver:*
Number Currently in Your Care
Type of Case?*

Family Preservation (children have never been removed)Family Preservation (children reunified)Relative placement -safety planRelative placement -DFCS legal custody (relative cannot be currently receiving stipend from DFCS)CPS investigationDFCS legal custody-Parent physical placement
Is the family receiving any services from DFCS?
What types of services is the family receiving (please include all that apply)?

CounselingParenting classSubstance Abuse Treatment/CounselingBehavioral AidParenting AidAnger ManagementOther
Other?
Please indicate the needs of the children and family:*
Referring Worker's Signature:*

Clear
Today's Date:*

MonthDayYear
Date
Should be Empty:

Together For Families

PRIMARY CAREGIVER

CHILDREN: