Resilient Futures Referral Form
Caregiver/Participant Information
Please indicate all caregivers who plan to attend the program.
Caregiver 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relationship to child
*
Caregiver 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to child
Caregiver Availability and Preferences
Times are in EST!
Select the caregiver's preference or availability (program is 5 consecutive weeks)
*
Thursdays - 5:30-7pm EST, virtual
Fridays - 1:00-2:30pm EST, virtual
I am available either of these times
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
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.
Referral Source
Information for individual completing this form.
Name
First Name
Last Name
Agency
Email
example@example.com
Save and Continue Later
Submit
Should be Empty: