Antioch C.A.R.E.S. PROGRAM REFERRAL FORM
Supportive Services for Families residing in Antioch Send Referrals to: AntiochCARES@Pacificclinics.org
Date of service request: Name of referring person or agency:
Contact number and/or email of referring person, if applicable:
Referring person or agency type: ☐ Family/ Friends ☐ Children & Family Services ☐ Community Organization ☐ School District ☐ Faith-Based ☐ Self ☐ Probation ☐ Law Enforcement Other (Please Specify):
Do any of the children in the home have a CFS social worker?: ☐Yes ☐No CFS Social Worker’s Information: Name:
Phone: Email:
Is there a pregnant or parenting teen in the home?: ☐Yes ☐No
Caregiver 1’s Name:
Caregiver 2’s Name:
Caregiver 1: Ethnicity: Marital Status:
Caregiver 2: Ethnicity:
Home Phone: Cell Phone:
Date of Birth:
Date of Birth:
*Home Address: City: Antioch Zip Code:
E-Mail:
*For additional addresses, please input on page two
Name:
Are there more than 4 children in the home? ☐Yes ☐No (If additional children exist please note below)
Services Needed:
Case Management
Transportation
Family Activities
Other:
Please list additional children, caregivers, relevant addresses, family strengths, and needs or concerns (Please provide a brief description of the family situation/history, and areas needing assistance that are not included above.):
For Antioch C.A.R.E.S. Staff Use Only. Antioch C.A.R.E.S. Staff attempted to contact family on (dates): Candidacy Recommendation: