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Family Support Specialist 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
Tell us more about who is the Sender of the referral.
Date of Referral
-
Month
-
Day
Year
Date Picker Icon
Name of Referring Person:
First Name
Last Name
Organization (if applicable)
Relationship to the Family
Please Select
Wraparound Care Coordinator
Community Partner
Family/Friend
Mental Health Provider
OFSN Employee
Self
Referrer's Phone Number:
Please enter a valid phone number.
Referrer's Email
example@example.com
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Parent/Caregiver Information
Name of Parent/Caregiver
First Name
Last Name
Date of Birth
Relationship to the Child/Youth
Please Select
Parent
Grandparent
Guardian
Foster Parent
Kinship
Other
Gender Identity
Pronoun
Primary Language
Race/Ethnicity
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
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Youth Information
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
Additional Information you would like to add?
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Do you have an additional Child / Youth's information to add
*
Yes
No
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Youth Information
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
Additional Information you would like to add?
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Family Information
What Type of Support is the Family looking for?
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
Non
Other
Has Family agreed to Family Support
Yes
No
Other
Submit
Should be Empty: