Referral Program Form

Prior to referring:

*Parent must receive a minimum of 3 referrals, no combined referrals for couples, each parent applies individually

*Parent must demonstrate a willingness to change and eagerness to learn

*Parent must have shown 2 months of consistent visitation

*Parent must demonstrate progress on court-ordered service plan

*Parent must have no Domestic Violence charges

*If addiction is involved, parent must have completed Drug Assessment and be enrolled in appropriate support program, actively working towards sobriety

Parent must be willing to:

*Confirm visit

*Arrive 10 mins prior to visit and remain 10 mins after for debrief

*Engage in goal-setting and planning of visits

*Engage with mentor with monthly communication and monthly group activity

*Engage with Foster Parents, Social Worker, Counselor, Parent Coach and Mentor with respect and teachability

*Attend Trauma Counseling- not required to use Hope Spring Community Counselor but recommended for consistency of care with integrated collaborative approach

Name of Referring Party

First NameLast Name

Referring Party Email

example@example.com

Referring Party Phone Number

Please enter a valid phone number.

Relationship to Parent

How Long Have You Known the Parent?

Name of Parent Being Referred

First NameLast Name

Parent Email

example@example.com

Parent Phone Number

Please enter a valid phone number.

Name, Gender, Age of Child(ren)

If More Than 1 Child, Are They Placed in Same Foster Home?

YesNoOther

Placing Agency

Date Case Was Opened

Reason for Removal

History of Removals

Is Parent Currently Consistently Working Plan?

YesNo

If Yes, How Long Have They Been Consistently Working Plan?

Parent Communication

Responds and InitiatesInconsistentUnresponsive

What Support System Does Parent Have?

What Strengths Do You See in Parent?

What Weaknesses Do You See in This Parent That Might Hold Them Back from Success?

In Your Opinion, What Makes This Parent a Candidate for Change?

Have Foster Parent(s) Communicated Support for Reunification?

YesNoUnsure

What support services do you anticipate this family may need in addition to visitation and one-on-one parenting coaching? (These are not guaranteed on-site, but knowing needs at intake allows our team to better assess needs and communicate what we can offer at the time of intake based on availability and space.) Please check all that apply:

Parenting classesCounseling - adultCounseling - play therapy and/or teen counselingLike skills classes - cooking, maintaining a home, healthy routine, family safetySpecial-needs parentBudget and family financesConnection to free community resources - job readiness, ESL, etc.Foreign language translation services

Signature

Referral for Visitation and Support

Referring Party Information

Hope Spring Community will contact CPS/Empower prior to initiation of visitation.

Case Details