Resilient Futures Referral Form
Caregiver/Participant Information
Please indicate all caregivers who plan to attend the program.
Caregiver's Name
*
First Name
Last Name
Caregiver's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver's Email
*
example@example.com
Caregiver's Relationship to child
*
Caregiver 2 - Name
First Name
Last Name
Caregiver 2 - Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Caregiver 2 - Email
example@example.com
Caregiver 2 - Relationship to child
Select the caregiver's preference or availability (program is 5 consecutive weeks)
Mondays - 5:30-7pm EST, in-person at Mission Kids office
Thursdays - 2:00-3:30pm EST, virtual
Family Information and Eligibility
Did the caregiver receive the informational flyer about the Resilient Futures pilot?
Yes
No
Yes, but study details such as pre/post measures and incentives not discussed
Does the caregiver speak English fluently?
Yes
No
Brief description of reason for referral/eligibility
(ex: physical abuse, sexual abuse, trafficking, community violence, etc.)
Indicate the caregiver's level of support for the child:
Please Select
Unsupportive
Supportive
Very supportive
Does the identified child or other children in the home demonstrate problematic sexual behavior?
Yes - identified child
Yes - other children at home
No
Other
Is the child and/or family currently receiving mental health services?
Please Select
Yes
No
On waitlist
Unknown
Please provide additional information about the family and/or case that you believe may be relevant or helpful.
Example: relationship to AP, Forensic Interview Complete, Y/N disclosure, etc.
Logistics
Does the family require transportation to in-person sessions via Lyft?
Yes
No
Does the family require childcare for evening sessions held at Mission Kids?
Yes
No
Unknown at this time
Please provide the name(s), approximate age(s), and any notable information for EACH child who requires care during sessions:
NOTE: Childcare is only provided on Monday evenings at Mission Kids
Please use the space below to share additional information about this referral that was not captured in this form.
Referral Source
Referral Name
First Name
Last Name
Referral Agency
Referral Email Address
example@example.com
Please contact Kaylee with questions: kmccormick@missionkidscac.org
How did you hear about the Resilient Futures Program?
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