Child First Referral Form

Request for Service (RFS)

**This form is HIPAA compliant**
Person Making Request for Service
Name*

First NameLast Name
Name of Referring Agency*
Telephone Number*
Please enter a valid phone number.
Email*
example@example.com
RFS Source Type*

Court PersonnelChild Welfare/Child Protective ServicesChild Developmental Services ProviderDomestic Violence Agency or ShelterEarly Childcare Provider/PartnershipFaith based organizationFamily resource centerHealth ProviderMental Health ProviderPublic Health Service/DepartmentSchool SystemSelfShelterSubstance Abuse Program
Child Referred for Services
Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child DOB*

MonthDayYear
Date
Child Gender*

MaleFemaleTransgender MaleTransgender FemaleGender Non-ConformingPrefer not to say
Language*

EnglishSpanishOther, please specify below:
Other Language
Funding Source*

County Human ServicesMedicaidPrivate insuranceTri-CareUnknown
Case #/Medicaid State ID #/Member Insurance ID/DoD Benefits Number(TriCare):
Adult To Be Involved In Services
Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
Please enter a valid phone number.
Relation to child (add description below):*
Who holds physical custody of the child?*

First NameLast Name
Who holds medical decision making rights for the child?

First NameLast Name
Address For Home Visits
Will the home visits take place at the child’s physical address?*

YesNoUnknown at this time
If 'No,' please enter the address below:
Address for Home Visits (If different from Child’s physical address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Request for Service
Check all that apply:*

Basic needs (e.g., housing, heat, food,TANF, SNAP)Child developmental/educational concernsChild behavioral/emotional concerns(Home/School/Child Care)Child exposure to violence (community/domestic)Child abuse/neglectNeed for parenting educationImminent risk of or recent out-of-home placementImminent risk of or recent child expulsion from child care or schoolHomelessness or risk of family evictionMajor child/family health concernsParent concerns (health/substance abuse/educational)Service coordination needs
REASONS FOR RFS NARRATIVE: Please include events that led to the referral, other agencies involved with the family, and whether the family has previous history with Child First if applicable.*
I First Name* Last Name* , give permission for this referral to be sent to Child First affiliate agency and for information to be sent to the Child First National Service Office. I understand that I will be contacted by the Child First affiliate agency directly to learn more about Child First and if it is an appropriate service for the child named on this request.
Yo Primer Nombre* Apellido* , doy permiso para que esta solicitud se envíe a
la agencia afiliada a Child First y para que la información se envíe a la
Oficina de Servicio Nacional de Child First. Entiendo que la agencia afiliada a
Child First se comunicará conmigo directamente para darme más información sobre
Child First y si este es un servicio apropiado para el niño/a nombrado en esta
solicitud.
Legal Guardian/Referent Signature:*

Clear
Date:*

MonthDayYear
Date
Some of our Colorado Child First sites are participating in an randomized control trial (RCT) that aims to understand the impacts of the CF program on caregivers, children, and families. The sites who are participating will randomly assign families into the Child First program. 60% of families will be assigned to Child First. 40% will be assigned to other Early Childhood Mental Health programs.
Should be Empty:

Request for Service (RFS)

Person Making Request for Service

Child Referred for Services

Adult To Be Involved In Services

Address For Home Visits

If 'No,' please enter the address below:

Reason for Request for Service