Team Dad

T.E.A.M. Dad Agency Referral Form
Name of father*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Primary Phone Number*
Other Phone Number
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Languages Spoken*

EnglishSpanishHaitian CreoleOther
Marital Status

MarriedSingleDivorcedSeparatedWidower
Does this participant have any children?

No, this is/will be first childYes, has other children
Number of children if more than 1
Name of Parent/Guardian if father is under the age of 18
Relationship to Participant
Mom and Infant/Child Information
Mom Name
Mom DOB
Child/Infant Name (Youngest)
Child/Infant DOB(Youngest)
Referral Status

Mother is in Healthy StartMother is in Other Home Visiting ProgramMother is pregnant and NOT receiving any Home Visiting ServicesInfant is in Healthy StartInfant is in Other Home Visiting ProgramInfant is NOT receiving any Home Visiting Services
Person Making Referral*
Date Referred

MonthDayYear
Date
Agency/Program
Phone Number*
Email Address
example@example.com
Fax Number
Best method of contacting Dad (Phone, Text, Email)
The client has consented to share the information on this form with and be contacted by CI&R. The client consents that information can be shared with one or more of the following collaborating agencies: Escambia County Healthy Start Coalition, Healthy Families Florida, Children's Home Society and Florida Department of Health in Escambia County for providing services. The client understands that this information will be confidential.
Signature

Clear
Date

MonthDayYear
Date
( Participant orParent/Legal Guardian)

This form will expire 60 days from date of signature.
Should be Empty: