Referring Worker Contact Information
Client Placement Information
Please note: placement information is necessary to enable RFS workers to coordinate and facilitate
Interactive Parenting Support (supervised visitation) services.
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: firstname.lastname@example.org
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 email@example.com)
Your Referral has been received!
Thank you for allowing us the continued opportunity
to support our community.