FRC Referral Form

Family Resource Center Referral Form

Kinship, Parenting Education, My Community Cares, Parent Partner, Youth Development
Person Submitting the Referral
DCFS Case #
What services are you requesting?
Click here to view descriptions for each service.

X
Program Descriptions

PARENTING EDUCATION
NPP: The Nurturing Parenting Program (NPP) helps parents build positive, day-to-day parenting skills. Classes focus on common parenting challenges and creating more structure, communication, and connection for both parents and children.

TBRI: Trust-Based Relational Intervention (TBRI) helps families build stronger relationships with their children, especially when trauma or attachment challenges are present. TBRI focuses on connection, empowerment, and correction while helping parents build strong bonds, structure, and trust in the home.

KINSHIP
Helps adults providing full time care for a child who is not biologically their own. We help connect caregivers to resources and support to help the child and home stay safe, stable, and cared for.

PARENT PARTNER
Supports parents involved with the foster care system. Parents work with someone who has been through similar challenges and can help them understand the court process, services, and next steps.

YOUTH DEVELOPMENT
Supports teens ages 14-17 and those aging out of the foster care system. Services include life skills, peer support, connection to resources, and support as youth learn to navigate adulthood.

MY COMMUNITY CARES
Helps parents connect to local resources and support for their family. We work alongside families to help with parenting support, school, jobs, basic needs, and other challenges at home.

MCC LEGAL SERVICES
Helps qualifying families with minor children who need support with civil legal issues. Services may include help with family matters, housing, public benefits, and other legal concerns that affect the home and family.

TBRI ADVOCATE
Gives families one-on-one support from a trained TBRI coach. Families receive hands-on help using TBRI skills and building stronger connection, structure, and trust in the home.
Parenting Education Type
- Referring Party's Name
  
  First NameLast Name
- Referring Party Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Referring Party Email
  example@example.com
- Referring Party's DCFS Department Affiliation
- Youth Name
  
  First NameLast Name
- Gender
- Date of Birth
  
  MonthDayYear
- Ethnicity
- Marital Status
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Please list name, date of birth, phone number, email address, and relationship to the client for all other adult household members.
- Relationship to Youth
  
  Other
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Race
- Primary Client's Name
  
  First NameLast Name
- Gender
- Date of Birth
  
  MonthDayYear
- Ethnicity
- Marital Status
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Please list name, date of birth, phone number, email address, and relationship to the client for all other adult household members.
- How many children are within this family unit?
  Any more than 4 will be listed in the additional space.
- Primary Client's Relationship to Child #1
  
  Other
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Race
- Is child #1 placed with the primary client?
- Please list name, relationship, phone number, and address of placement for child #1.
- Primary Client's Relationship to Child #2
  
  Other
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Race
- Is child #2 placed with the primary client?
- Please list name, relationship, phone number, and address of placement for child #2.
- Primary Client's Relationship to Child #3
  
  Other
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Race
- Is child #3 placed with the primary client?
- Please list name, relationship, phone number, and address of placement for child #3.
- Primary Client's Relationship to Child #4
  
  Other
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Gender
- Race
- Is child #4 placed with the primary client?
- Please list name, relationship, phone number and address of placement for child #4.
- Please list name, date of birth, race, gender and relationship to primary client, and placement information for all other children.
- Name of Adverse Party:
- Number of People Living in the Household:
- Total Household Income
- Source of Income:
- What VYJ Program are you currently involved in?
- Are you a citizen of the USA?
- What Services are currently being provided to the family?
  
  Other
- Please give agency name and contact information for each service provided
- In a few sentences, please provide an overview of family circumstances
  Please list any additional information that would be helpful in determining the needs of the client. Please provide details. (Background, psychological/medical history, court involvement, etc.)
- In a few sentences, please let us know how the FRC can assist your family.
- Please upload the latest documents applicable to the case.
  
  Files may include: Safety Assessment, CSP Court Ordered Safety Plan, ISP Instanter Order Safety Plan, SP CW Safety Plan, Form XI (services requested for foster/adoptive home), Trauma and Behavioral Health Screen, Assessment of Family Functioning, Case Plans, and Youth Transition Plans.
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- Should be Empty: