Section 1: Referral Source Information

If you are a self-referring parent or caregiver, skip to Section 2.

Referral Agency:   

Agency Type:   --None--Child Welfare Community Centers (e.g. YMCA, B&G Club) DHS-Other (e.g. TANF, Judicial/Probation) Early Childhood Councils Early Childhood Education/Child Care Early Intervention Family Resource Center Medical Provider Mental Health Other Home Visitation Program (e.g. Bright Beginnings, PAT, NFP) Public Health (WIC) Self-Referral Substance Treatment Other

Agency Type Other:   

Referred By:   

Phone:   

Email:   

Section 2: Primary Caregiver

This is information for the primary caregiver who will be receiving services.

First Name:*   

Last Name:*   

Date Of Birth:*   

Gender:*   

Primary Language:*   

Address:   

City:   

Zip:   

County:*

Home Phone:   

Cell Phone:   

Email:   

Ok to Leave Message

Ok to text

Where did the primary caregiver hear about SafeCare?*

Section 3: Primary Child

This is information for the child five or under who will primarily be receiving services.

First Name:*   

Last Name:*   

Date Of Birth:*   

Gender:*   

Primary Language:*   

Section 4: Eligibility

Is there a child 5 or younger residing in the home?*   

We know the following family characteristics may be private and sensitive information. We need to ask this question to see if your family/the family being referred may be eligible for the SafeCare program. Please check all characteristics that apply to your family/the family being referred.

Any Prior Child Welfare Child has Special Need Childhood Abuse/Neglect Housing Issues Less Than HS Education Mental Health Multiple Child Under 5 Public Assistance Recipient Single Parent Stepfather/Unrelated Male CG Substance Abuse Violence Young Caregiver

Any Prior Child Welfare Child has Special Need Childhood Abuse/Neglect Housing Issues Less Than HS Education Mental Health Multiple Child Under 5 Public Assistance Recipient Single Parent Stepfather/Unrelated Male CG Substance Abuse Violence Young Caregiver

Comments / Additional Information:

Section 5: SafeCare Release of Information (Optional)

I hereby authorize the person, agency, or institution entered below to supply information requested by SafeCare Colorado, including relevant health information and results of assessments and consultations. I release the person, agency, or institution from any and all liability for supplying such information.

I also authorize SafeCare Colorado to supply information obtained directly from me, or from any person, agency, or institution which has provided information to SafeCare Colorado about me, to the person, agency, or institution entered below. I release SafeCare Colorado from any and all liability for supplying such information.

Printed name of person, agency, or institution:

This authorization is given only in connection with its use by SafeCare Colorado in its administration of services and for no other purpose. I certify this request has been made voluntarily and that the information given above is accurate. I understand that this consent may be revoked at any time, with the exception that disclosure of information has already occurred prior to the receipt of the revocation by the above named provider. If written revocation is not received, the authorization will be considered valid for a period of time not to exceed 1 year from the date of signing.

By checking this box, I am agreeing to the above terms.

Client Name:

Date:[ 9/24/2017 ]

Verbal Consent Received

Referral Signature:

Referral Signature Date:[ 9/24/2017 ]