Resource Center Referral Form

Family Resource Center Referral Form

This form is for Cobb or Bartow County DFCS, Court partners (FTC, GAL, Parent Attorneys, CASA), approved agencies, and Advocates for Children internal programs. Established clients should contact us directly at 770-264-6352 (Cobb Office) or 770-387-1143 x 242 (Bartow Office). Referrals are for access to the Family Resource Center for basic needs and family navigation assistance.
COUNTY:
REFERRAL SOURCE:
Reason for Referral
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.Format: (000) 000-0000.
HAS FAMILY AGREED TO BE REFERRED? (Family MUST agree to be referred before submitting application).
If you answered "NO," please do not submit this referral.
Type of Case?
Is the family receiving any services from DFCS?
What types of services is the family receiving (please include all that apply)?

Other
Other?
PRIMARY CAREGIVER
Name of Primary Caregiver:

First NameLast Name
Date of Birth of Primary Caregiver

MonthDayYear
Date
Best Phone Number for Primary Caregiver
Please enter a valid phone number.Format: (000) 000-0000.
Email for Primary Caregiver
example@example.com
Race & Ethnicity of Primary Caregiver

Other
Type a question
Gender Identity of Primary Caregiver:
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is the Primary Caregiver a Veteran?
Does the Primary Caregiver have a Disability?:
Primary language spoken in the home
English, Spanish, etc…
Primary Caregiver's Relationship to Children:
Mother, Father, Grandparent, Caregiver, etc....
Primary Caregiver's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many TOTAL individuals currently reside within the primary caregiver's home?
Including primary caregiver and children
How many ADULTS currently reside in the primary caregiver's home?
DO NOT INCLUDE PRIMARY CAREGIVER OR CHILDREN
Name of Adult #1:

First Name (NOT PRIMARY CAREGIVER)Last Name
DOB of Adult #1:

MonthDayYear
Date
Race & Ethnicity of Adult #1:
Black/African American, White, Hispanic/Latina, Asian, etc...
Gender Identity of Adult #1:
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is Adult #1 a Veteran?
Does Adult #1 have a Disability?
Name of Adult #2:

First NameLast Name
DOB of Adult #2:

MonthDayYear
Date
Race & Ethnicity of Adult #2
Black/African American, White, Hispanic/Latina, Asian, etc...
Gender Identity of Adult #2
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is Adult #2 a Veteran?
Does Adult #2 have a Disability?
Name of Adult #3:

First NameLast Name
DOB of Adult #3?

MonthDayYear
Date
Race & Ethnicity of Adult #3
Black/African American, White, Hispanic/Latina, Asian, etc...
Gender Identity of Adult #3
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is Adult #3 a Veteran?
Does Adult #3 have a Disability?
Name of Adult #4:

First NameLast Name
DOB of Adult #4?

MonthDayYear
Date
Race & Ethnicity of Adult #4
Black/African American, White, Hispanic/Latina, Asian, etc...
Gender Identity of Adult #4
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is Adult #4 a Veteran?
Does Adult #4 have a Disability?
Name of Adult #5:

First NameLast Name
DOB of Adult #5?

MonthDayYear
Date
Race & Ethnicity of Adult #5
Black/African American, White, Hispanic/Latina, Asian, etc...
Gender Identity of Adult #5
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is Adult #5 a Veteran?
Does Adult #5 have a Disability?
Name of Adult #6:

First NameLast Name
DOB of Adult #6?

MonthDayYear
Date
Race & Ethnicity of Adult #6
Black/African American, White, Hispanic/Latina, Asian, etc...
Gender Identity of Adult #6
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is Adult #6 a Veteran?
Does Adult #6 have a Disability?
Name of Adult #7:

First NameLast Name
DOB of Adult #7?

MonthDayYear
Date
Race & Ethnicity of Adult #7
Black/African American, White, Hispanic/Latina, Asian, etc...
Gender Identity of Adult #7
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is Adult #7 a Veteran?
Does Adult #7 have a Disability?
Name of Adult #8:

First NameLast Name
DOB of Adult #8?

MonthDayYear
Date
Race & Ethnicity of Adult #8
Black/African American, White, Hispanic/Latina, Asian, etc...
Gender Identity of Adult #8
Woman/girl, Man/boy, Transgender, Non-Binary, etc.....
Is Adult #8 a Veteran?
Does Adult #8 have a Disability?
If there are 8+ ADULTS please type Name, DOB, Race & Ethnicity, Gender Identity, Veteran Status, and if they are disabled for EACH additional person.
John Doe, 11//11/2000, White, Male, Veteran, Disabled
CHILDREN:
Number of Minor Children in the Care of the Primary Caregiver:
Number Currently in Your Care
Child #1 Name:

First NameLast Name
Child #1 Date of Birth

MonthDayYear
Date
Child #2 Name:

First NameLast Name
Child #2 Date of Birth

MonthDayYear
Date
Child #3 Name:

First NameLast Name
Child #3 Date of Birth

MonthDayYear
Date
Child #4 Name:

First NameLast Name
Child #4 Date of Birth

MonthDayYear
Date
Child #5 Name:

First NameLast Name
Child #5 Date of Birth

MonthDayYear
Date
Child #6 Name:

First NameLast Name
Child #6 Date of Birth

MonthDayYear
Date
Child #7 Name:

First NameLast Name
Child #7 Date of Birth

MonthDayYear
Date
Child #8 Name:

First NameLast Name
Child #8 Date of Birth

MonthDayYear
Date
Child #9 Name:

First NameLast Name
Child #9 Date of Birth

MonthDayYear
Date
Child #10 Name:

First NameLast Name
Child #10 Date of Birth

MonthDayYear
Date
10+ Children please add names and date of birth:
Name: John Doe DOB: 1/1/2000
Please indicate the needs of the children and family:
Family Risk Factors
Reason for Referral/Issues to Address:
Referring Worker's Signature:
Today's Date:

MonthDayYear
Date
Should be Empty:

PRIMARY CAREGIVER

CHILDREN: