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SafeCare Colorado Referral Form
Section 1: Referral Source Information
If you are a self-referring parent or caregiver, skip to Section 2.
Referral Agency:
Agency Type:
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
ECMH Specialist
Warm Line
Website
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:*
[
2/27/2021
]
Gender:*
--None--
Male
Female
Other
Unknown
Primary Language:*
--None--
English
Spanish
Other
American Sign Language (ASL)
Amharic
Arabic
Armenian
Cambodian
Cantonese
Chinese
English Sign Language (ESL)
Farsi
French
German
Greek
Guamanian
Haitian-Creole
Hawaiian
Hebrew
Hindi
Hmong
Hungarian
Ilocano
Indonesian
Italian
Japanese
Korean
Lao
Mandarin
Mien
Other Non-English
Polish
Polynesian
Portuguese
Romany
Rumanian
Russian
Samoan
Scandinavian
Somalia/Somalian Dialect
Tagalog
Thai
Turkish
Vietnamese
Yiddish
Yugoslavian
Physical Address:
City:
Zip:
County:*
--None--
Rio Blanco
Cheyenne
Routt
Archuleta
Adams
Alamosa
Arapahoe
Baca
Bent
Chaffee
Denver
Crowley
Custer
Dolores
El Paso
Huerfano
Jefferson
Kiowa
La Plata
Logan
Las Animas
Mesa
Mineral
Moffat
Montezuma
Morgan
Otero
Phillips
Saguache
Prowers
Pueblo
Rio Grande
San Juan
Sedgwick
Southern Ute Tribe
Ute Mountain Ute Tribe
Washington
Weld
Yuma
Conejos
Costilla
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:
[
2/27/2021
]
Gender:
--None--
Male
Female
Other
Unknown
Primary Language:
--None--
English
Spanish
Other
American Sign Language (ASL)
Amharic
Arabic
Armenian
Cambodian
Cantonese
Chinese
English Sign Language (ESL)
Farsi
French
German
Greek
Guamanian
Haitian-Creole
Hawaiian
Hebrew
Hindi
Hmong
Hungarian
Ilocano
Indonesian
Italian
Japanese
Korean
Lao
Mandarin
Mien
Other Non-English
Polish
Polynesian
Portuguese
Romany
Rumanian
Russian
Samoan
Scandinavian
Somalia/Somalian Dialect
Tagalog
Thai
Turkish
Vietnamese
Yiddish
Yugoslavian
Section 4: Eligibility
Is there a child 5 or younger residing in the home?*
--None--
Yes
No
Unknown
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
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:
[
2/27/2021
]
Verbal Consent Received
Referral Signature:
Referral Signature Date:
[
2/27/2021
]