Agency Referral Form

Instructions: Please fill out this form on behalf of the family to help them access the best programs and services at Erie Family Center. Ensure all sections are completed accurately to provide us with the necessary information to support the family's needs effectively. Once submitted, a copy will be sent to you, and a Referral Specialist will contact you if there are any questions.

Parent/Guardian Name(Required)

First Last

Family Information(Required)

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Who were you referred by?(Required)

First Name Last Name

Agency(Required)

Phone(Required)

Insurance Provider(Required)

Insurance ID #(Required)

# of Children(Required)

Pregnant?(Required)

Pregnancy Due Date(Required)

1. Child's Name(Required)

1. Date of Birth(Required)

1. Custody other than parent

2. Child's Name(Required)

2. Date of Birth(Required)

2. Custody other than parent

3. Child's Name(Required)

3. Date of Birth(Required)

3. Custody other than parent

4. Child's Name(Required)

4. Date of Birth(Required)

4. Custody other than parent

5. Child's Name(Required)

5. Date of Birth(Required)

5. Custody other than parent

More than 5 children?(Required)

Please include remaining children's names and birthdays(Required)

Reason for Referral

OCY Involved?

Caseworker's Name(Required)

First Last

Phone(Required)

Involvement in other Community Programs:

Recommended Programs(Required)

Parents As Teachers – In home visitation focusing on parent-child interactions, child development and family support (prenatal-age 5).

Perinatal Doula – Free birth and post-partum support to women in NWPA.

1-2-3 Magic – Positive relationship techniques with your toddler through adolescence.

Incredible Years – Parenting/social and emotional behavior support for children ages 3-12. Specialties in Spanish, Autism, and Intellectual Disabilities

PAT-OCY – Parent child interactions/family support/family activities (birth-age 5). For families and foster families who are partnering with the Office of Children and Youth.

Plans of Safe Care – Recovery support through case management – for any caregiver and baby prenatally until baby’s first birthday.

Motherhood Support Initiative – Supportive parenting group for mothers.

24/7 Dad - Supportive parenting group for fathers or any male who is involved in a child’s life.

Substance(s) Used:(Required)

Agency Referral Form

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