Section 1: Referral Source Information
If you are a self-referring parent or caregiver, skip to Section 2.
Agency Type Other:
Section 3: Primary Child
This is information for the child five or under who will primarily be receiving services.
Date Of Birth:*
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.
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.
Date:[ 11/22/2017 ]
Verbal Consent Received
Referral Signature Date:[ 11/22/2017 ]