Welcome to Resilient Families, a service provided by our Children's Mental and Behavioral Health Program.

Family Information

Resilient Families is a service that provides support for "families" who need help staying together due to challenges related to a mental health diagnosis of at least one member of the family who is 3 through 17 years of age. For this reason we need to identify a "child of focus", the family member who is 3 through 17 years and also at least one parent/guardian. Thank you for your cooperation.
What is the parent/guardian's name?*

First NameLast Name
Parent/Guardian's Email Address*
example@example.com
Parent/Guardian's Phone Number*
Please enter a valid phone number.
Parent/Guardian's Relationship to the Child of Focus*
(Examples include: Parent, Aunt, Uncle, Medical Consenter, Grandparent, etc . . . )
Name of Child*

First NameLast Name
Child's date of birth?*

MonthDayYear
Date
Reason for Contacting Resilient Families*
Please describe the reason/circumstances leading you to seek our services.

Additional Information

Based on your responses to to the eligibility questions it appears Resilient Families might be a good option to support your family. Please provide this additional information to help expedite the process of completing the referral. Thank you for your cooperation.
Family Address Information

Why do you need my address? We use this information to determin service eligibility and ensure we can serve families in our coverage area.
Child's Primary Residence (Physical Address)*

Street Address

Street Address Line 2

CityState

Zip Code
Is child's primary residence different from the parent/guardian's physical address?*

No, child lives with their parent/guardianYes, child is not currently living with their parent/guardian
Parent/Guardian's Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Child's Mental or Behavioral Health Services (select all that apply)*

Currently in services;Previously in services;Never in services
Current Mental or Behavioral Health Services*
Please tell us about the services that the child is currently in (example: Counseling, Psychiatry, etc . . ) and include where the child receives these services (home, office, hospital, other).
Current medical, mental, and behavioral health providers including as much information as you have to share. Name, Credentials, Address, Phone Number, and website URL would be great!*
Tell us as much information as you can about current providers including name, credentials, addresses, phone numbers, and website addresses. (For example: Lily Smith, LPC, 333 Street, City, Zip, 999-999-9999)
Previous Mental or Behavioral Health Services*
Tell us about the services the child has participated in previously, but not currently. Include location of services and when those services ended. (Example: Counseling, at the counselors office, two weeks ago.)
Current Medications*
Please list any medications your child currently takes (including over-the-counter). If none, type "N/A". (example: Adderall 10mg daily, Melatonin 3mg at bedtime)

Thank you for completeting our form. You can still go back to review your responses if you wish. If you are satisfied with your responses then you are ready to tap the Submit button.

After tapping the Submit button you can expect to receive an email confirming your submission of this form and someone from our program will follow up with the parent/guardian indicated in the referral to discuss the options.
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Welcome to Resilient Families, a service provided by our Children's Mental and Behavioral Health Program.

Family Information

Eligibility Questions

Additional Information