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.
If "No" skip to "Parent Contact Information".
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: email@example.com
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 requesting IPS/visitation services with an active protective order,
RFS cannot start services until documentation is received to maintain compliance with court requirements.
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 firstname.lastname@example.org)