Strong Start Referral Form - The SAFE Alliance

Parent information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Do you live in Travis or Williamson County?*
- Yes
- No
Best time to contact (day and time)
Email*
Enter Email Confirm Email
Phone
Primary child name*
Primary child date of birth*
MM slash DD slash YYYY
Number of children, ages 0-5, living in the home*
Please enter a number from 0 to 5.
Number of children, ages 6 or older, living in the home*
Please enter a number from 0 to 25.
Preferred language (check all that apply)*
- English
- Spanish
- ASL
- Other
If other language is preferred, which language(s)
Is parent Deaf, DeafBlind, DeafDisabled, or Hard of Hearing?
- Yes
- No
Is parent's child Deaf, DeafBlind, DeafDisabled, or Hard of Hearing,?
- Yes
- No
Preferred service type*
- Individual Session
- Group Session
- No Preference
Preferred service time*
- Morning
- Afternoon
- Evening
Preferred service day*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Preferred curriculum type
- Triple P
- Nurturing parenting
- Fatherhood
- Parents as teachers
- No preference
Have you or are you currently experiencing any of the following? (check all that apply)*
- Difficulty with parent/child interaction
- Parent/Guardian and/or child suffers from depression/anxiety
- Teen parent
- High parent conflict/separation/divorce
- High general stress level
- Parent/guardian has high frustration level with child's behavior
- Parent/guardian would benefit from child development education
- Social isolation of family/parent/guardian-lack of support
- Homelessness
- Non-traditional family structure-especially single parent with lack of social support and/or a high number of children in the household
- Low income
- Substance abuse
- Low education
- Parent experienced maltreatment in childhood
- Survivor of domestic violence
- Parenting a child with special needs (if selected, please provide additional info below)
- Current or former foster youth parent
If child has special needs, please provide information about those needs
Do you wish to complete your parenting classes in person, over the phone, or virtually?
- In person
- Over the phone
- Virtually (Zoom, FaceTime, Skype, etc.)
Do you have access to the internet and a device that will allow you to participate in virtual classes?
- Yes
- No
How did you hear about Strong Start?
Please tell us more about your answer to the previous question. (For example, if you answered "From my child's doctor," please tell us who the doctor is or the name of the clinic. Or if you answered "Other," please tell us more.)
Permission: MUST BE COMPLETED BY PARENT*
- By checking this box, I (parent) give permission for this referring agency to give the following contact information to Strong Start and Project HOPES staff as part of a referral process to the Strong Start program. I agree for my contact information to only be utilized for referral purposes and only to be released to Strong Start and Project HOPES staff.
Date*
MM slash DD slash YYYY
Referring agency information
Name
Agency name
Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Is parent currently engaged in an open CPS case?
- Yes
- No
Has the family had a substantiated CPS case?
- Yes
- No
Is parent education court ordered?
- Yes
- No

Parent information

Referring agency information