FEC Client Referral

Client Referral
By submitting a referral for a client through this website, you consent to Plumas Rural Services using the provided information solely for the purpose of connecting the referred child and family with appropriate services offered by programs within the agency.

We will make every effort to maintain the confidentiality of the information you share. This agreement applies specifically only to data collected through this website.
*

I Agree

Please select one*

This is a self-referral for my own child/familyI am a professional referring a client
Reason for filling this out…*
How did you hear about us?*
Other (please specify)*

Parent/Family Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Email*
example@example.com
Phone Type*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred method of contact*
Family Role (select all that apply)*

ParentFoster parentKinshipSurrogateGuardianship
Ethnicity*
Primary Language*
Top 2 concerns or prior interventions used at home or school*

Child Information
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Child's Ethnicity*
Child's Qualifying Category*
School Name*
If in school, what grade is the child in?*
Does this child have Regional Center services?*
Please Select*

My child has an IEPMy child has a 504My child is currently being assessed for special educationNone of the aboveOther (Please specify below)
Add Child #2?

YesNo

Child #2 Information
#2 Child's Name*

First NameLast Name
#2 Date of Birth*

MonthDayYear
Date
#2 Child's Ethnicity*
#2 Child's Qualifying Category*
#2 School Name*
#2 If in school, what grade is the child in?*
#2 Does this child have Regional Center services?*
#2 Please Select*

My child has an IEPMy child has a 504My child is currently being assessed for special educationNone of the aboveOther (Please specify below)
Add Child #3?

YesNo

Child #3 Information
#3 Child's Name*

First NameLast Name
#3 Date of Birth*

MonthDayYear
Date
#3 Child's Ethnicity*
#3 Child's Qualifying Category*
#3 School Name*
#3 If in school, what grade is the child in?*
#3 Does this child have Regional Center services?*
#3 Please Select*

My child has an IEPMy child has a 504My child is currently being assessed for special educationNone of the aboveOther (Please specify below)
Add Child #4?

YesNo

Child #4 Information
#4 Child's Name*

First NameLast Name
#4 Date of Birth*

MonthDayYear
Date
#4 Child's Ethnicity*
#4 Child's Qualifying Category*
#4 School Name*
#4 If in school, what grade is the child in?*
#4 Does this child have Regional Center services?*
#4 Please Select*

My child has an IEPMy child has a 504My child is currently being assessed for special educationNone of the aboveOther (Please specify below)

Thank you for your referral. Click submit below and Family Empowerment personnel will review and act upon your referral.
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Client Referral