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Tuscarawas County Family & Children First
Supporting our county's most valuable resource – children and families
(330) 343-2286
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Service Coordination
Ages 0-3
Ages 3-21
Referral Form
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Tusc County Directory of Services (Spanish)
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Informational Brochure
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About
Members
By-Laws
Service Coordination
Ages 0-3
Ages 3-21
Referral Form
Resources
Local Resources
State Resources
Tusc County Directory of Services (English)
Tusc County Directory of Services (Spanish)
Resource Guide Advertiser Contract
Informational Brochure
Contact
Referral Form
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Service Coordination
Referral Form
Service Coordination Referral Form
Please complete both the referral and the release of information.
Download Form Offline
Release of Information
Youth Name (not just initials)
Date of Birth
Place of Birth
Sex
[Select One]
Male
Female
Race
[Select One]
White
African American
American Indian
Hispanic
Asian
Native Hawaiian
Other
Phone Number (18+)
Address
City
Zip
Current School
Grade Level
Education Type
Regular Education
Special Education
IEP
504
Social Security Number
Insurance Carrier
Current Youth Diagnoses (list all)
Current Medications (list all)
Name
Date of Birth
Relationship to Youth
Email
Phone Number
Alternative Phone Number
Address (if different from youth)
City
Zip
Employer
Name
Age
Relationship to Youth
Youth Involvement (Last 30 days - check all that apply)
Juvenile Court
Children Services/JFS
Physician/Hospital
Department of Youth Services
Board of Developmental Disabilities
Mental Health
Substance Abuse Treatment
Respite
Other
Comments
Youth Needs/Concerns (Check all that apply)
Alcohol/Drug
Poverty
Special Education
Child Abuse
Delinquent
Unruly
Help Me Grow
Mental Health
Child Neglect
Physical Health/Medical
Developmental Disabilities
Autism Spectrum Disorder
Primary Care Physician
Behavior Problems
Legal Issues
Runaway
Housing
School Problems
Suicidal
Other
Comments
Reasons for Referral/Additional Information
Is the youth at risk for placement out of the home?
Yes
No
If YES, rate the risk (1-low, 10-high)
1
2
3
4
5
6
7
8
9
10
Is the youth need of transition/step-down services back to the community?
Yes
No
Is the youth/family in need of support and/or services to maintain the youth in the home/community?
Yes
No
Is the youth at risk of juvenile court involvement?
Yes
No
NA
Has the family been educated and agreeable to this referral to service coordination?
Yes
No
NA
Referral Completed By
Referral Date
Agency
Phone
Email
SUBMIT
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