Submit a Referral | Riverside Family Support

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

Client (Child/Youth) Full Name

Client (Child/Youth) Date of Birth

Referring Worker Contact Information

Referring Worker Name

Referring Worker Email Address

Referring Worker Phone Number

Referral Agency

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?

Yes

If "Yes", please enter name & client's relationship to current physical guardian

Client Current Physical Address

Client or Current Physical Custodian's Phone Number

Is this a TFC placement?

Yes

If "Yes", please enter name & contact information for TFC worker.

Parent Contact Information

Names of Biological Parent / Previous Guardian / Relative

Biological Parent/Relative's Address

Biological Parent/Relative's Phone Number

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.

Reason for Referral

Please check here if there is a current Protective Order in place for the family

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?

CSA / FAPT Funded

DJJ Funds

PSSF Funded

Private Pay

If CSA Funded - What date were services approved to begin?

If the identified client is participating in the Diversionary program, please enter projected date of discharge

Unit / Hours approved or desired per month

Your Referral has been received!

Thank you for allowing us the continued opportunity

to support our community.

Submit a Referral: Job Application

Submit a Service Referral

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

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