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Circle of Security Parenting Program - Referral Form
Complete the below referral form. After submission, Foundling staff will be in touch about next steps.
Referral Source Information
Is this referral to the Circle of Security Parenting program being completed by an outside party, organization, or agency?
(Required)
Yes - this form is being completed by an outside party (a caseworker, school, hospital, etc.)
No - this form is being completed by the guardian interested in joining the program
Referral Source Name
(Required)
First
Last
Referral Source Agency
(Required)
Referral Source Phone
(Required)
Referral Source Email
(Required)
Youth Information
Please enter information for one child under the age of 8:
Legal Name
(Required)
First
Last
Chosen Name (if different than legal name)
First
Last
Home Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Ethnicity/Race
American Indian
Asian / Pacific Islander
Black / African American
Hispanic / Latino
White
Other
Sex Assigned at Birth
(Required)
Male
Female
Intersex
Pronouns
(Required)
Primary Language
(Required)
School
Grade
Is this youth currently in foster care?
(Required)
Yes
No
Name of Foster Care Case Planner
First
Last
Phone Number of Foster Care Case Planner
Guardian Information
Legal Guardian Name
(Required)
First
Last
Relationship
(Required)
Primary Language
(Required)
Guardian Phone
(Required)
Guardian Email
(Required)
Notes
Reason for Referral
How did you hear about us?
(Required)
Came to a Foundling-hosted event
General community event
Friend or coworker
Online search (Google, Bing, etc)
Social media: Instagram, Twitter (X), other
Other
Describe reason for referral to the Circle of Security Parenting program:
(Required)
Describe any significant life events that may have had a large impact on the child's mental health (including any relevant information):
(Required)
Does the child have a known history (current or past) of:
(Required)
Suicidal Ideation / Behavior
Self-Injurious Behavior
Homicidal Ideation
Hallucinations / Delusions
Substance / Alcohol Use
None
Unknown
Please explain:
Does the child have a known trauma history?
(Required)
Yes
No
Unknown
Please check off any known sources of trauma:
Domestic Violence
Physical Abuse / Assault
Sexual Abuse / Assault
Sudden or Violent Death of Loved One
Natural Disaster, Fire, or Explosion
Serious Accident
Life-threatening Injury or Illness
Combat or Exposure to War-zone
Community Violence
Other
Does the child have a known history of previous mental health treatment?
(Required)
Yes
No
Unknown
Please explain (treatment type, dates, reason, results):
Diagnosis given (if known):
Does the child have a known history of psychiatric hospitalization?
(Required)
Yes
No
Unknown
Please explain (name of hospital, date, length of stay, reason):
Does the child have a known history of psychiatric medication?
(Required)
Yes
No
Unknown
Please explain (include medication, dosage, dates, reason, results):
Required Documentation
A completed Consent Bundle (download here:
English version
/
Spanish version
) and a copy of the youth's insurance card is required for enrollment in the program.
Are you currently able to upload a completed copy of the Consent Bundle?
(Required)
Yes
No
Please upload the completed Consent Bundle here:
(Required)
Max. file size: 50 MB.
Are you currently able to upload the youth's insurance card?
(Required)
Yes
No
Please upload the insurance card here:
(Required)
Max. file size: 50 MB.
I acknowledge that this referral is not complete until a signed consent form and copy of insurance card have been provided. These items can also be emailed to COSP@NYFoundling.org. Please include the name/date of birth of the youth being referred if emailing separately.
(Required)
Yes
Please attach any additional pertinent information - these items include (but are not limited to) safety assessments, intake paperwork, past psychiatric records, past medical records, or past educational records:
Drop files here or
Select files
Max. file size: 50 MB.
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