Strong Start Referral Form - The SAFE Alliance

Referring Agency Information
Name
Agency name
Title
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Parent Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Best time to contact (day and time)
Email
Does parent live in Travis or Williamson County*
- Yes
- No
Please re-enter zip code
ZIP / Postal Code
Is parent currently engaged in an open CPS case?*
- Yes
- No
Has the family had a substantiated CPS case?*
- Yes
- No
Primary child name*
Primary child date of birth*
Date Format: 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
Eligibility factors (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
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*
Date Format: MM slash DD slash YYYY

Referring Agency Information

Parent Information