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: firstname.lastname@example.org Client (Child/Youth) Date of Birth Referring Worker Contact Information Client Placement Information
Is client placed in Foster Care or Relative placement?
If "No" skip to "Parent Contact Information". Parent Contact Information 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:
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.
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:
FAPT Approval for RFS services?