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SafeCare Colorado Referral Form
Please Wait...
Part 1: Information about the Referral Source
Please provide some information about the referral agency:
Referral Agency:
Agency Type:
Child Welfare
Community Centers (e.g. YMCA, B&G Club)
DHS-Other (e.g. TANF, Judicial/Probation)
Early Childhood Councils
Early Childhood Education/Child Care
Early Intervention
Family Resource Center
Medical Provider
Mental Health
Other Home Visitation Program (e.g. Bright Beginnings, PAT, NFP)
Public Health (WIC)
Substance Treatment
Other
ECMH Specialist
State Support Line
Website
ECMH Consultant
Online
Support Line
Trails Referral ID:*
If You Selected “Other” Please Explain:
Name of Person Making Referral:
Phone Number:
Email Address:
Part 2: Parent / Caregiver Information
Please provide information for the primary parent or caregiver who will receive services from SafeCare Colorado:
First Name :*
Last Name :*
Date of Birth:*
[
10/31/2024
]
Gender:*
--None--
Male
Female
Other
Unknown
Nonbinary
Primary Language:*
--None--
English
Spanish
Other
American Sign Language (ASL)
Amharic
Arabic
Armenian
Cambodian
Cantonese
Chinese
English Sign Language (ESL)
Farsi
French
German
Greek
Guamanian
Haitian-Creole
Hawaiian
Hebrew
Hindi
Hmong
Hungarian
Ilocano
Indonesian
Italian
Japanese
Korean
Lao
Mandarin
Mien
Other Non-English
Polish
Polynesian
Portuguese
Romany
Rumanian
Russian
Samoan
Scandinavian
Somalia/Somalian Dialect
Tagalog
Thai
Turkish
Vietnamese
Yiddish
Yugoslavian
Home Address:
City:
Zip:
County:*
--None--
Adams
Alamosa
Arapahoe
Archuleta
Baca
Bent
Chaffee
Crowley
Custer
Denver
Dolores
El Paso
Huerfano
Jefferson
Kiowa
La Plata
Larimer
Las Animas
Logan
Mineral
Moffat
Montezuma
Morgan
Otero
Prowers
Pueblo
Rio Grande
Saguache
San Juan
Southern Ute Tribe
Ute Mountain Ute Tribe
Weld
Conejos
Costilla
Routt
Cheyenne
Rio Blanco
Home Phone:
Cell Phone:
Email Address:
OK to leave a message on voicemail?
OK to text?
Where did you hear about SafeCare Colorado?*
Part 3: Child Information
Please provide information for the child, age five or under, who will primarily receive services from SafeCare Colorado
First Name:
Last Name:
Date of Birth:
[
10/31/2024
]
Gender:
--None--
Male
Female
Other
Unknown
Nonbinary
Primary Language:
--None--
English
Spanish
Other
American Sign Language (ASL)
Amharic
Arabic
Armenian
Cambodian
Cantonese
Chinese
English Sign Language (ESL)
Farsi
French
German
Greek
Guamanian
Haitian-Creole
Hawaiian
Hebrew
Hindi
Hmong
Hungarian
Ilocano
Indonesian
Italian
Japanese
Korean
Lao
Mandarin
Mien
Other Non-English
Polish
Polynesian
Portuguese
Romany
Rumanian
Russian
Samoan
Scandinavian
Somalia/Somalian Dialect
Tagalog
Thai
Turkish
Vietnamese
Yiddish
Yugoslavian
Part 4: Eligibility to Participate
Please answer a few questions so that we can determine if your family is eligible to receive services from SafeCare Colorado
Is there a child age 5 or younger living in the home?*
--None--
Yes
No
Unknown
We recognize that this information is private and sensitive, and it will be kept strictly confidential. The information will not be shared in any way beyond determining your eligibility. We need to ask this question to confirm if your family is eligible to participate in SafeCare Colorado.
Please select all characteristics that apply to your family. Hold down the “Ctrl” key to select more than one.*
Past contact with child welfare
Child has Special Needs
Childhood Abuse or Neglect
Housing instability/homelessness
Less than high school education
More than one child under age 5
Receives public assistance
Single Parent
Stepfather/unrelated male in home
Substance Abuse
Violence
Parent/caregiver under age 20
Mental Health
Comments/Additional Information
Part 5: SafeCare Colorado Release of Information
This section is optional
I hereby authorize the person, agency, or institution entered below to supply information requested by SafeCare Colorado, including relevant health information and results of assessments and consultations. I release the person, agency, or institution from any and all liability for supplying such information.
I also authorize SafeCare Colorado to supply information obtained directly from me, or from any person, agency, or institution which has provided information to SafeCare Colorado about me, to the person, agency, or institution entered below. I release SafeCare Colorado from any and all liability for supplying such information.
Printed name of person, agency, or institution:
This authorization is given only in connection with its use by SafeCare Colorado in its administration of services and for no other purpose. I certify this request has been made voluntarily and that the information given above is accurate. I understand that this consent may be revoked at any time, with the exception that disclosure of information has already occurred prior to the receipt of the revocation by the above named provider. If written revocation is not received, the authorization will be considered valid for a period of time not to exceed 1 year from the date of signing.
By checking this box, I am agreeing to the above terms.
Client Name:
Date:
[
10/31/2024
]
Verbal Consent Received?
Referral Signature:
Referral Signature Date:
[
10/31/2024
]