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Submit a Service Referral

Client Information 

Please ensure all text fields are completed to the best of your ability prior to submitting the form to prevent delays in beginning services. 
With any questions, feel free to contact: admin@riversidefamilysupport.com

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Referring Worker Contact Information

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Client Placement Information

Please note: placement information is necessary to enable RFS workers to coordinate and facilitate

Interactive Parenting Support (supervised visitation) services. 

Is client placed in Foster Care or Relative placement?
Is this a TFC placement?

Parent Contact Information 

Please include the names of all biological family members (or previous guardian family members) that will be participating in requested services with RFS. 

Lack of contact information may result in delays in initiating services. If contact info changes following referral submission, feel free to email:  admin@riversidefamilysupport.com

Referral Information

Please enter presenting concerns and reason for referral for RFS services. Note information about the client/family, potential goals or desired outcome of RFS involvement, frequency/severity of behavioral symptoms, relevant family history, etc.

Important to Note: If this referral has been submitted to more than one agency, please indicate

this information to prevent duplicate service efforts. 

If you would like to add any additional documentation,

(Affidavit, Service Plan, protective order, etc) feel free to do so here:

(additional documentation can be sent to admin@riversidefamilysupport.com)

Upload File

Funding Information

How will services be funded?

Your Referral has been received!

Thank you for allowing us the continued opportunity

to support our community. 

Submit a Referral: Job Application
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