Education Support Referral Program Form

CCDN Education Support Service Referral Form

Please complete the referral form below. This referral form is to refer youth and adults to Community Care Development Network's Education Support Services Program. Please read each section and follow instructions. Please note there are required documents needed to submit this referral. The referring agency must complete the form and submit the following: Documents needed to submit the referral include court order, Release of Information, Intake Face Sheet, Behavioral Analysis and/or Social History
Potential Client Information
Name*

First NameLast Name
E-mail*
Phone Number 1*

Area CodePhone Number
Phone Number 2*

Area CodePhone Number
Service Requested (Check all that apply)*

Youth MentoringParent MentoringEducation ServicesMotherhood InitiativeFatherhood InitiativeJob ResourcesFinancial LiteracyOther

Referral details
Referral Agency Name*
Contact Person Name*

First NameLast Name
Referral E-mail*
Phone Number*

Area CodePhone Number
What is your relationship to this referral? (i.e. service agency, counselor, social worker, attorney, etc.)
Please let us know about the referral. Include as much information as possible, Guardian at Litem (GAL), Attorney, Parole Officer, Judge, Counselors, Social Workers (DHR or Other Agency), Counselors etc. Name, Phone Number, and Email Address:*
Referrals should include essential participant information and any relevant background details to facilitate the enrollment process.
1. Documents needed to submit the referral include court order, Release of Information, Intake Face Sheet, Behavioral Analysis and/or Social History
2. Participants under the age of 18 will need to be enrolled by a parent or legal guardian. Legal guardians may be identified as Biological Parent(s), Temporary Custodian, GAL, or DHR Representative. We will accept enrollment by a Parole Officer, GAL, or Legal Attorney in cases where there is no parental or legal guardian available but will need documentation indicating this.
3. In the event there needs to be special considerations for special enrollment as stated in bullet point 3 under the referral process, the acting legal guardian will need to enroll, and GAL will need to provide the referral via the link listed above.
4. Court-Ordered participants will need to abide by the order in which the judge has stated in the order.
REQUIRED: Please upload additional documents here (examples behavior analysis, court order, release of information, insurance, etc.):*

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Is this referral involved with the court system or DHR?*

YesNo
If the referral is under DHR, include the worker's name and direct phone number.
Does the referral have a behavioral challenges?(i.e. Mental Health, Violent Behavior, Anger Issues, etc.)*

YesNo
If yes, check all that applies...*

Family CourtCity CourtCounty CourtDHROther

Please let the client know they will need sto submit the following documents.

Client File and Document Checklist
- Valid Identification – State, Military, Continuum, Prison I.D., or State Driver’s License.
- Proof of Residence - Utility Bill or Lease.
- Proof of Income - Retirement Statement, Check Stub, Unemployment, Food Stamp, Social Security, or SSI/SSDI Letter.
- Other if indicated married. Need a check stub or some form of income from a family member.
If clients are homeless:
- Address to the homeless shelter or transitional housing facility they are in
- Address to where they are dwelling
  Copy of Food Stamp Letter
- Valid Identification – State, Military, Continuum, Prison I.D., or State Driver’s License.
NOTE: SSI Letter or Food Stamp Letter may act as proof of residence.

This does not impede the service we will provide. If you need assistance obtaining identification or other human support services needs, please let us know.

To Submit documents you can upload them into this referral form, email them to tamika@ccommunitycaredn.org, or fax and send them to (205) 449-5353‬.
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CCDN Education Support Service Referral Form

Potential Client Information

Referral details