Family Tree Lancaster Request for Services V202503

Complete this form to request enrolling your family in the Family Tree Program and receive services at Positive Changes Lancaster location. After you submit, a Case Manager or Therapist will evaluate your family's eligibility and then will respond to you via email within 48 hours. Eligible families will be scheduled at that time.

The Family Tree Program provides family counseling at no cost to eligible families in Denton and Dallas Counties. (Administered by CCD Counseling PA). Click here to find other provider locations in Denton and Dallas counties.

The Family Tree Program generally provides family counseling to families who are experiencing change in life circumstances, school issues, behavioral issues, communication breakdowns, grief, and general family struggles. Eligible families are those who can be successfully treated in brief therapy (6 -12 sessions).

The information in this form will help us determine if this is the correct service for you and your family. If you are eligible, we will be emailing you to get you scheduled. If not, we will try to connect your family to a more appropriate level of care.

Are you concerned about your child hurting themselves (suicidal) or another person?

YesNo

If this is a life-threatening emergency, please call 911!

If this is not an emergency, we encourage you to seek immediate help for your child.

Denton County - Call 800-762-0157

Dallas County - Call 866.260.8000 or 844.672.5700

Once your child has been evaluated and stabilized, we may be a good fit for your family. Please feel free to return and complete this request form at that time.

Parent Name*

First NameLast Name

Relationship to Youth*

Parent Email - This is the email we will use to contact you. Please provide an email that you regularly check. If you don't hear from us, be sure to check your Spam or Junk folders.*

Confirmation Emailexample@example.com

Youth Name*

First NameLast Name

Child's current age*

What county do you live in?*

DentonDallasOther

Every Texas County has a FAYS program. This program serves Dallas and Denton counties. Click here to find a FAYS provider in other counties.

County Trigger

TRUE

County Trigger

TRUE

Briefly describe the challenges you hope to resolve in brief family therapy (up to 6 sessions):*

Has this youth ever been diagnosed?*

YesNo

Has this youth previously received counseling?*

YesNo

If the answer was yes to either of the previous questions, please provide additional information here.

Preferred days/times for your family counseling:

Phone Number for Appointment Confirmation Text(s) *

Referral Name: If you were referred by someone (e.g. School Counselor), please provide their name and the name of their organization (e.g. name of school).

Referral NameReferral Organization

Please provide any additional information you would like (number of household members to participate, transportation limitations, previous contact with one of our providers, etc) :

Consent: Before providing services to a minor, we must ensure that the correct adults have provided consent. Sometimes,this is the birth parents. Sometimes the right to consent has been changed or assigned by a divorce decree, custody agreement, adoption decree, letter of guardianship, other court order, or some other legal document.

Has this child ever been named in a document that designated which adults can provide consent?*

YesNo

Texas law requires the therapist to have a copy (physical or electronic)of this legal document. Do you have a copy you can bring to your intake?

YesNo

Texas law requires the therapist to have a copy of this legal document. We will not be able to schedule your intake at this time, but we will provide you with an email to contact when you have that document in hand.

Great! Please bring it to your intake session or email it to your therapist in advance. Texas law requires us to have a copy and we cannot meet with you until we have it. Thanks.

Are there any current lawsuits, or do you anticipate any lawsuits to be filed related to the custody or visitation of the child(ren)?*

YesNo

If you are looking for services related to a custody or visitation suit, we are not likely your best choice. We recommend you visit: the Coparenting Texas website to find experienced forensic therapists.

Unless parental rights have been limited by the courts, it is best practice in our program to work with all of the parent/caregivers during our family counseling. This sometimes conflicts with the goals of parents involved in legal disputes with one another.

Please share any additional information about the lawsuit to assist us in determining your family's eligibility for the program