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Oregon Family Support Network Referral Form
4263 Commercial St. SE, Suite 300, Salem OR 97302, Office: 503.363.8066 | Fax: 503.390.3161 | Email: www.ofsn.org
Referrer's Information
Date of Referral
-
Month
-
Day
Year
Date Picker Icon
Is this form being filled out/completed for Parents As Teachers in Coos, Curry or Douglas Counties? (Note: PAT is designed for Families with children of ages 5 year or younger and or Expectant Parent(s))
*
Yes
No
Referrer's Relationship to Family
Please Select
Community Partner
Caseworker
Early Childhood Program
Family/Friend
Health Clinic
Medical Provider
Mental Health Provider
OFSN Employee
Oregon Department of Human Services (ODHS)
School
Self
WIC Office
Wraparound Coordinator
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Referrers Information
Referrer Name:
*
First Name
Last Name
Organization (if applicable):
Referrer's Phone Number:
Please enter primary contact number.
Format: (000) 000-0000.
Referrer's Email
example@example.com
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Referrer's Information
For Parents as Teachers Referral
Referrers Name:
*
First Name
Last Name
Organization:
District or Branch:
Optional
Phone Number of Referrer:
Please enter primary contact number.
Format: (000) 000-0000.
Email of Referrer:
example@example.com
Supervisor's Name (Optional)
First Name
Last Name
Phone Number
Please enter primary contact number.
Format: (000) 000-0000.
Email
example@example.com
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Parent/Caregiver Information
Name of Parent/Caregiver
*
First Name
Last Name
Family/Case Number:
For Families engaged with ODHS
Relationship to the Child/Youth
Please Select
Parent
Grandparent
Guardian
Resource Parent
Kinship (Aunts, Uncles, Cousins, Other)
Sibling
Other
If "Other", describe your relationship to Child/Youth
Date of Birth
Primary Language
Gender
Race/Ethnicity
Address (City and Postal / Zip Code Required)
*
Street Address
Street Address Line 2
*City
State / Province
*Postal / Zip Code
County:
Phone Number
Please enter primary contact number.
Format: (000) 000-0000.
Email
example@example.com
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Is there another Parent/Caregiver's you would like to add to this referral?
*
Yes
No
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Additional Parent Information
Parent/Caregivers Name
First Name
Last Name
Relationship to Child/Youth
Please Select
Parent
Grandparent
Guardian
Foster Parent
Kinship
Other
If "Other" describe your relationship
Date of Birth
Gender Identity
Race/Ethnicity
Pronoun
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Child / Youth Information
Placement of Child / Youth (for Parents as Teachers Use only)
In Home
Other
Child / Youth's Name
First Name
Last Name
Date of Birth
Gender Identity
Pronoun
Race/Ethnicity
Does the Child or Youth have Oregon Health Plan
Yes
No
If Yes, select the type of OHP Plan
Please Select
Care Oregon
Trillium
Pacific Source
OHP - Open Card
Polk County
Other
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Do you have an additional Child / Youth's information to add
*
Yes
No
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Additional Youth Information
Placement of Child / Youth (For Parents As Teachers Use Only)
In Home
Substitute Placement
Child / Youth's Name
First Name
Last Name
Date of Birth
Gender Identity
Pronoun
Race/Ethnicity
Does the Child or Youth have Oregon Health Plan
Yes
No
If Yes, select the type of OHP Plan
Please Select
Care Oregon
Trillium
Pacific Source
OHP - Open Card
Polk County
Other
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Additional Referral Information
What Type of Support is the Family seeking? (check all that apply)
Basic Needs
System Navigation
Parent Support / Skill Building
Community Based Peer Support
Wraparound
Other
Current Services Involved (check all that applies)
Mental Health Provider
Wraparound
DHS / CWS
School-based Services
Juvenile Justice
DD Services
None
Other
Has the parent/caregiver agreed to be contacted by Oregon Family Support Network
*
Yes
No
Is there additional information you would like to share.
Submit
Should be Empty: