First Parent's Name
First Name
Last Name
Phone and Email
Second Parent's Name
First Name
Last Name
Phone and Email
Marital Status
Single
Married
Divorced
Separated
Other
Children's Names and Ages in the Home
Stable Work Currently?
Yes
No
Stable Housing Currently?
Yes
No
DFPS Investigator's Name
DFPS Caseworker's Name, Phone, and Email
Type of Referral (priority given to OTP cases for one-on-one coaching)
OTP
FBSS
Other
Is Parent(s) Receptive to Support?
Yes
No
One parent is but the other isn't
Does the Family Have a Support Network?
Yes
No
What Are Some of the Parents' Strengths & Weaknesses?
What Services Have They Already Participated In, If Any?
What Services & Supports Do You Feel the Parent/Family Lack?
What Frequency of Services Do You Recommend?
Weekly
Biweekly
Monthly
Other
Would Parent Benefit from Teen Mother Support Group?
Yes
No
N/A
Would Parent Benefit from Newborn/Infant Care Support?
Yes
No
N/A
Who Should We Send Monthly Reports To? (Include Name, Email, Phone, and Preferred Method)
Additional Info We Should Be Aware Of
Following receipt of referral, our team will contact Parent to set up an intake interview and set them up with a parenting coach. Our case manager will reach out to let the investigator know what supports will be offered to Parent. We will email a monthly report. Parent will sign consent for release of reports at intake.
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