Resilient Futures Self-Referral Form
If you need assistance completing this form, please contact Kaylee at kmccormick@missionkidscac.org or 484-687-2990 ext. 1209
Caregiver/Participant Information
Please include all caregivers who plan to attend the program
Caregiver 1 name
*
Email
example@example.com
Phone Number
Preferred contact method
Phone
Email
Either
Relationship to child
Caregiver 2 name
Email
example@example.com
Phone Number
Relationship to child
Family Information and Eligibility
Please complete to the best of your ability and level of comfort. Note: all information is used for eligibility purposes ONLY and will not be shared with anyone outside of the Resilient Futures team at Mission Kids Child Advocacy Center. Limits to confidentiality apply.
Did you review the informational pages about the Resilient Futures program?
Yes
No
Yes, but I would like to speak to someone directly for more information
Are you fluent in English?
Yes
No
To your comfort, please provide a brief explanation for your reason for referral/desire to attend Resilient Futures. For example: a child in my care has experienced or witnessed physical abuse, sexual abuse, trafficking, community violence, etc.
THIS INFORMATION WILL BE KEPT PRIVATE AND IS ONLY TO DETERMINE YOUR ELIGIBILITY FOR THE PROGRAM.
Please check all that apply. Your participation in Resilient Futures will not be shared with the parties below or impact your attendance.
My child is receiving mental health services
I have an open case with OCY and/or law enforcement.
My child/family is on a wait-list for mental health services
Other
If your child/children has recently disclosed or experienced child abuse, please rate your current level of support for your child
Please Select
Unsupportive
Supportive
Very Supportive
N/A
Please provide additional information about your child/family or situation that you believe may be relevant or helpful
For example: relationship to perpetrator, child has or has not disclosed, had a forensic interview, etc.
Availability and Preferences
Resilient Futures is offered throughout the year, both in-person and virtually in the evenings and daytime. Groups that fill first will be run first. THIS FORM IS FOR VIRTUAL SESSIONS ONLY AND IN EST!
Select your preference or availability (program is 5 consecutive weeks)*
Thursdays - 5:30-7pm EST, virtual
Fridays - 1:00-2:30pm EST, virtual
I am not available for any of the above, but would like to join a group in the future. Please contact me when additional groups open up.
I can attend either days/times above.
If you are located in or around Montgomery County, PA and are interested in an in-person group, please select below.
Yes, I am nearby and would like to attend in-person sessions
Yes, but prefer virtual
No
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