Kids on Track Referral Form Child over 3 months

Southern Tier Kids on Track

Intra-partnership Service Referral Form: Child Older than 3 Months
Organizations in our partnership have several voluntary programs designed to provide parents in New York’s Allegany, Chemung, Livingston, Schuyler, Steuben, Tompkins, and Tioga Counties with referrals, resources, information, education and support. The programs are at no cost to families.

Please click here for the list of organizations on our partnership.

Intra-partnership Service Referral Form: CHILD OVER 3 MONTHS

(*Please use the KOT Prenatal / Newborn Referral for PREGNANT MOMS AND BABIES UNDER 3 MONTHS of age;
** Please close the loop on the referral by letting the source know if the family engaged in services.)
Source of referral:
Name:*
Agency:
Phone Number*
Please enter a valid phone number.
Referrer Email:
example@example.com
Consenting Parent or Caregiver
First Name*
Last Name*
DOB:*
Address:*
City, State, Zip:*
County:*
Phone Number*
Please enter a valid phone number.
Pronouns:
Relationship to Child:*
Email:
example@example.com
Primary Parent Insurance:

MedicaidNo insurancePrivate Insurance
Primary Parent Relationship Status:

SingleMarriedDivorcedSeparatedWidowedPartneredRelationship/Partnership not listed
Secondary Parent or Caregiver
First Name:
Last Name:
DOB:
Address:
City,State, Zip:
County:
Phone Number
Please enter a valid phone number.
Email:
example@example.com
Relationship to Child:
Referred Child
First Name*
Last Name*
DOB:*
Sex assigned at birth*

MaleFemaleIntersex
Pediatrician:
School or Child Care:

Other Children in the Home

	First Name:	Last Name:	Gender	DOB	School or Child Care
1
2
3
4
5
6
7

Reason for Referral:*
Date:

MonthDayYear
Date
Consenting Parent Signature:*

Clear
By signing above, I give permission for the appropriate partner programs to contact me to offer more information and services available to me and my family. I consent to have referral information electronically stored and shared within the software systems used by the STKOT Network of health and social service partners.
Consenting Parent Name:*
Verbal Signature?*
Date:

MonthDayYear
Date
Consent to Participate in the Unite Us Network
By consenting, you agree to share information with a Network of health and social service partners powered by Unite Us software. The Network is made up of entities and individuals who are directly involved in your care or payment of care. Your personal information may be shared securely on the Network in accordance with privacy laws to connect you with services.

This consent covers all information shared by you or by anyone that has the right to share information on your behalf and is relevant to the recipient's involvement in your care or payment for your care. You can always limit the information you provide on the Network by requesting to have it removed.

To understand how your information may be used and kept safe on the Network, please see uniteus.com/privacy-policy/.

If you no longer want your information shared on the Network, you can email consent@uniteus.com or ask any Network partner.
Should be Empty:

Southern Tier Kids on Track

Consenting Parent or Caregiver

Secondary Parent or Caregiver

Referred Child