Deaf Services
Request Form for The Foundling’s Family Services for Deaf Children and Adults
First and Last name:
*
First
Last
Phone
Email:
Reason for Referral
*
Is this an ACS referral?
No
Yes
ACS Referral Details
CPS Worker
First
Last
CPS Worker Phone Number
CPS Worker Email
CPS Supervisor
First
Last
CPS Supervisor Phone Number
CPS Supervisor Email
Case Initiation Date (CID)
MM slash DD slash YYYY
Family Structure and Composition
Please enter as much information as possible. Services are available to families that contain a Deaf or Hard-of-Hearing family member AND a minor (under age 18) in the household.
Name(s) of children
Last Name
First Name
DOB
Deaf, Hard of Hearing, or Hearing?
Primary Caregiver (Case name)
Last Name
First Name
DOB
Deaf, Hard of Hearing, or Hearing?
Is there a secondary caregiver?
No
Yes
Secondary Caregiver (Case name)
Last Name
First Name
DOB
Deaf, Hard of Hearing, or Hearing?
What is the primary language spoken in the home?
Are there any concerns or past history of the following:
Domestic Violence
Substance Abuse
Mental Health
Homicidal/Suicidal Ideation
Truancy
What services are you interested in learning about, or receiving?
Case Management
Mental Health
Parenting Skills
Crisis Intervention
Housing Resources
Domestic Violence
Substance Abuse
Referral & Community Links
Advocacy
Other
If Other, please specify
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