Family Center Treatment Referral – The SPARC Foundation

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- Culture and Team
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Family Centered Treatment

Please check one *

FCTR Referral – when substance misuse is a primary behavioral issue in the family

FCT Referral – when the primary behavioral issue in the family is NOT substance misuse

Not Sure

NAME OF PERSON BEING REFERRED *

Address *

Address

City

State/Province

Zip/Postal

Country

DOB

PARENT/GUARDIAN OF PERSON BEING REFERRED

COUNTY OF PARENT/GUARDIAN RESIDENCE

LANGUAGE PREFERENCE

PARENT/GUARDIAN PHONE NUMBER

Is the family currently involved with DSS?

Yes

No

If yes, for how long? *

Agency and Social Worker’s Name: *

Agency’s Phone Number:

Social Worker’s Direct Number:

Social Worker’s Email: *

Reason for Referral: (Focus on family systems challenges; Focus on family goals such as removal prevention or reunification: Let us know if parental substance use/abuse is a factor)

FILE PLEASE UPLOAD MOST RECENT COMPREHENSIVE CLINICAL ASSESSMENT

Maximum file size: 314.57MB

Is there a history of substance use in the family?

Yes

No

Is the person being referred on the Medicaid Tailored Plan?

Yes

No

Medicaid #: *

Primary parent on Medicad card:

SIS #: (for FCTR referrals only)

Does this referral have a current CCA (within the last 6 months)?

Yes

No

Date of referral:

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