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Fatherhood Engagement Referral Form
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This form has been modified since it was saved. Please review all fields before submitting.
Person making the referral: First and last name:
*
Your contact phone and/or email:
*
Father's Name
*
Mother's Name
*
Phone and/or email
*
Father's Zip Code
*
How many children does the father have all together?
*
Who are the children living with?
*
Has the father been contacted by DCSE?
*
-- Select One --
Yes
No
Unknown
Is the father employed?
*
-- Select One --
Yes
No
Unknown
Is the father incarcerated?
*
-- Select One --
Yes
No
Unknown
Where and how long?
Is the father part of the service plan?
*
-- Select One --
Yes
No
Unknown
Is case court involved?
*
-- Select One --
Yes
No
Unknown
Does the father have housing?
*
-- Select One --
Yes
No
Unknown
Are the parents living together?
*
-- Select One --
Yes
No
Unknown
Does the father have contact with child/children?
*
-- Select One --
Yes
No
Unknown
Domestic violence history?
*
-- Select One --
Yes
No
Unknown
Language assistance needed?
*
-- Select One --
Yes
No
Unknown
Mental health concerns?
*
-- Select One --
Yes
No
Unknown
Has paternity been established?
*
-- Select One --
Yes
No
Unknown
Does the father have family support?
*
-- Select One --
Yes
No
Unknown
Teenage father?
-- Select One --
Yes
No
Unknown
Is immigration a barrier for the father?
*
-- Select One --
Yes
No
Unknown
Substance abuse concerns?
*
-- Select One --
Yes
No
Unknown
Date of next court hearing?
*
Type of hearing
*
Date children entered care, if applicable. If not please enter N/A
*
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