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Oregon Family Support Network Referral Form
4263 Commercial St. SE, Suite 300, Salem OR 97302, Office: 503.363.8066 | Fax: 503.390.3161 | Website: www.ofsn.org
Date of Referral
-
Month
-
Day
Year
Date Picker Icon
What Type of Support is the Family seeking? (check all that apply)
*
OFSN Tabling Event Follow-up
Family Care Plan (FCP)
Community-Based Family Support Services (CBFSS)
Intensive In Home Behavioral Health Treatment (IBHT)
Mental Health Outpatient (MOPY)
Mobile Response Stabilization Services (MRSS)
Parents as Teachers (for Families with children of ages 5 year or younger and/or Expectant Parent(s) in Coos, Curry, or Douglas Counties)
Positive Parenting Program (Triple P)
Wraparound (WR)
Other
Attendee Name
First Name
Last Name
Attendee Email
example@example.com
Attendee Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer's Relationship to Family
Please Select
Community Partner
Caseworker
Early Childhood Program
Family/Friend
Health Clinic
Medical Provider
Mental Health Provider
OFSN Employee
Oregon Department of Human Services (ODHS)
School
Self
WIC Office
Wraparound Coordinator
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Referrer's Information
Referrer's Name
First Name
Last Name
Organization (if applicable)
District or Branch
Optional
Referrer's Phone Number
Please enter primary contact number.
Format: (000) 000-0000.
Referrer's Email
example@example.com
Supervisor's Name (Optional)
First Name
Last Name
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Parent/Caregiver Information
Name of Parent/Caregiver
*
First Name
Last Name
Family/Case Number (For Families engaged with ODHS)
Parent/Caregiver's Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Parent/Caregiver's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver County
*
Please Select
Baker
Benton
Clackamas
Clatsop
Columbia
Coos
Crook
Curry
Deschutes
Douglas
Gilliam
Grant
Harney
Hood River
Jackson
Jefferson
Josephine
Klamath
Lake
Lane
Lincoln
Linn
Malheur
Marion
Morrow
Multnomah
Polk
Sherman
Tillamook
Umatilla
Union
Wallowa
Wasco
Washington
Wheeler
Yamhill
Parent/Caregiver Phone Number
Please enter primary contact number.
Format: (000) 000-0000.
Parent/Caregiver Email
example@example.com
Parent/Caregiver's Demographics
Parent/Caregiver Race/Ethnicity
American Indian
Alaska Native
Canadian Inuit, Metis, or First Nation
Indigenous Mexican, Central American, or South American
Asian Indian
Cambodian
Chinese
Communities of Myanmar
Filipino
Hmong
Japanese
Korean
Laotian
South Asian
Vietnamese
Other Asian
African American
Afro-Caribbean
Ethiopian
Somali
Other African
Other Black Latinx Mexican
Latinx Mexican
Latinx Central American
Latinx South American
Other Hispanic/Latinx
Middle Eastern
North African
Chamoru (Chamorro)
Communities Micronesian Region
Marshallese
Samoan
Native Hawaiian
Other Pacific Islander
Eastern European
Slavic
Western European
Other White
Don't know
Don't want to answer
Did not answer/missing
I don’t just have one primary identity
Identify as Biracial or Multiracial
Other
Parent/Caregiver Preferred Language
Please Select
American Sign Language (ASL)
Arabic
Armenian
Basque
Bosnian
Burmese
Chinese
Contact Signing Variety of ASL (CSV)
Deaf - does not use ASL, SEE, PSE or CSV
East Indian/Pakistani Language (Specify if known)
Eastern European (Specify if known)
English
Farsi
French
German
Greek
Hindi
Japanese
Mandarin
None
Other
Other (Non-Eng)
Persian
Polish
Portugese
Portuguese
Russian
Sign Language
Spanish
Unknown
Parent/Caregiver Gender Identity
Boy, Man
Girl, Woman
Non-binary
Agender, No gender
Questioning
Fluid
Queer
Don't Know
Don't Want to Answer
Other
Parent/Caregiver Pronouns
She / Her
He / Him
They / Them
Prefer not to say / Decline to state
Other
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Is there another Parent/Caregiver you would like to add to this referral?
*
Yes
No
Should second Parent/Caregiver share family record?
*
Yes - both parents/caregivers should share family record
No - parents/caregivers should have individual records (generally for privacy purposes)
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Additional Parent/Caregiver Information
Name of Additional Parent/Caregiver
*
First Name
Last Name
Relationship to first Parent/Caregiver
Life Partner
Spouse
Other Family Member
Unknown
Other
Additional Parent/Caregiver's Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Additional Parent/Caregiver's Address (City and Postal / Zip Code Required)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional Parent/Caregiver's County
Please Select
Baker
Benton
Clackamas
Clatsop
Columbia
Coos
Crook
Curry
Deschutes
Douglas
Gilliam
Grant
Harney
Hood River
Jackson
Jefferson
Josephine
Klamath
Lake
Lane
Lincoln
Linn
Malheur
Marion
Morrow
Multnomah
Polk
Sherman
Tillamook
Umatilla
Union
Wallowa
Wasco
Washington
Wheeler
Yamhill
Additional Parent/Caregiver's Phone Number
Please enter primary contact number.
Format: (000) 000-0000.
Additional Parent/Caregiver's Email
example@example.com
Additional Parent/Caregiver's Demographics
Additional Parent/Caregiver Race/Ethnicity
American Indian
Alaska Native
Canadian Inuit, Metis, or First Nation
Indigenous Mexican, Central American, or South American
Asian Indian
Cambodian
Chinese
Communities of Myanmar
Filipino
Hmong
Japanese
Korean
Laotian
South Asian
Vietnamese
Other Asian
African American
Afro-Caribbean
Ethiopian
Somali
Other African
Other Black Latinx Mexican
Latinx Mexican
Latinx Central American
Latinx South American
Other Hispanic/Latinx
Middle Eastern
North African
Chamoru (Chamorro)
Communities Micronesian Region
Marshallese
Samoan
Native Hawaiian
Other Pacific Islander
Eastern European
Slavic
Western European
Other White
Don't know
Don't want to answer
Did not answer/missing
I don’t just have one primary identity
Identify as Biracial or Multiracial
Other
Additional Parent/Caregiver Preferred Language
Please Select
American Sign Language (ASL)
Arabic
Armenian
Basque
Bosnian
Burmese
Chinese
Contact Signing Variety of ASL (CSV)
Deaf - does not use ASL, SEE, PSE or CSV
East Indian/Pakistani Language (Specify if known)
Eastern European (Specify if known)
English
Farsi
French
German
Greek
Hindi
Japanese
Mandarin
None
Other
Other (Non-Eng)
Persian
Polish
Portugese
Portuguese
Russian
Sign Language
Spanish
Unknown
Additional Parent/Caregiver Gender Identity
Boy, Man
Girl, Woman
Non-binary
Agender, No gender
Questioning
Fluid
Queer
Don't Know
Don't Want to Answer
Other
Additional Parent/Caregiver Pronouns
She / Her
He / Him
They / Them
Prefer not to say / Decline to state
Other
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Child/Youth Information
Placement of Child / Youth (for Parents as Teachers Use only)
In Home
Other
Child/Youth's Name
First Name
Last Name
Child/Youth's Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Relationship to the Parent/Caregiver
Adopted Child
Child
Foster Child
Grandchild
Nephew or Niece
Stepchild
Unknown
Other
Does the Child or Youth have Oregon Health Plan
Yes
No
Select the type of OHP Plan
CareOregon
Trillium
Pacific Source
OHP - Open Card
Polk County
Other
Child/Youth's OHP Number
Child/Youth's OHP Begin Date
Child/Youth's Demographics
Child/Youth's Race/Ethnicity
American Indian
Alaska Native
Canadian Inuit, Metis, or First Nation
Indigenous Mexican, Central American, or South American
Asian Indian
Cambodian
Chinese
Communities of Myanmar
Filipino
Hmong
Japanese
Korean
Laotian
South Asian
Vietnamese
Other Asian
African American
Afro-Caribbean
Ethiopian
Somali
Other African
Other Black Latinx Mexican
Latinx Mexican
Latinx Central American
Latinx South American
Other Hispanic/Latinx
Middle Eastern
North African
Chamoru (Chamorro)
Communities Micronesian Region
Marshallese
Samoan
Native Hawaiian
Other Pacific Islander
Eastern European
Slavic
Western European
Other White
Don't know
Don't want to answer
Did not answer/missing
I don’t just have one primary identity
Identify as Biracial or Multiracial
Other
Child/Youth's Preferred Language
Please Select
American Sign Language (ASL)
Arabic
Armenian
Basque
Bosnian
Burmese
Chinese
Contact Signing Variety of ASL (CSV)
Deaf - does not use ASL, SEE, PSE or CSV
East Indian/Pakistani Language (Specify if known)
Eastern European (Specify if known)
English
Farsi
French
German
Greek
Hindi
Japanese
Mandarin
None
Other
Other (Non-Eng)
Persian
Polish
Portugese
Portuguese
Russian
Sign Language
Spanish
Unknown
Child/Youth's Gender Identity
Boy, Man
Girl, Woman
Non-binary
Agender, No gender
Questioning
Fluid
Queer
Don't Know
Don't Want to Answer
Other
Child/Youth's Pronouns
She / Her
He / Him
They / Them
Prefer not to say / Decline to state
Other
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Additional Child/Youth
Do you have an additional Child / Youth's information to add?
*
Yes
No
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Next
Additional Child/Youth Information
Placement of Additional Child/Youth (for Parents as Teachers Use only)
In Home
Substitute Placement
Additional Child/Youth's Name
First Name
Last Name
Additional Child/Youth's Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Relationship to the Parent/Caregiver
Adopted Child
Child
Foster Child
Grandchild
Nephew or Niece
Stepchild
Unknown
Other
Does the Additional Child or Youth have Oregon Health Plan
Yes
No
Select the type of OHP Plan
CareOregon
Trillium
Pacific Source
OHP - Open Card
Polk County
Other
Additional Child/Youth's OHP Number
Additional Child/Youth's OHP Begin Date
Additional Child/Youth's Demographics
Additional Child/Youth's Race/Ethnicity
American Indian
Alaska Native
Canadian Inuit, Metis, or First Nation
Indigenous Mexican, Central American, or South American
Asian Indian
Cambodian
Chinese
Communities of Myanmar
Filipino
Hmong
Japanese
Korean
Laotian
South Asian
Vietnamese
Other Asian
African American
Afro-Caribbean
Ethiopian
Somali
Other African
Other Black Latinx Mexican
Latinx Mexican
Latinx Central American
Latinx South American
Other Hispanic/Latinx
Middle Eastern
North African
Chamoru (Chamorro)
Communities Micronesian Region
Marshallese
Samoan
Native Hawaiian
Other Pacific Islander
Eastern European
Slavic
Western European
Other White
Don't know
Don't want to answer
Did not answer/missing
I don’t just have one primary identity
Identify as Biracial or Multiracial
Other
Additional Child/Youth's Preferred Language
Please Select
American Sign Language (ASL)
Arabic
Armenian
Basque
Bosnian
Burmese
Chinese
Contact Signing Variety of ASL (CSV)
Deaf - does not use ASL, SEE, PSE or CSV
East Indian/Pakistani Language (Specify if known)
Eastern European (Specify if known)
English
Farsi
French
German
Greek
Hindi
Japanese
Mandarin
None
Other
Other (Non-Eng)
Persian
Polish
Portugese
Portuguese
Russian
Sign Language
Spanish
Unknown
Additional Child/Youth's Gender Identity
Boy, Man
Girl, Woman
Non-binary
Agender, No gender
Questioning
Fluid
Queer
Don't Know
Don't Want to Answer
Other
Additional Child/Youth's Pronouns
She / Her
He / Him
They / Them
Prefer not to say / Decline to state
Other
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Additional Referral Information
Current Services Involved (check all that applies)
Mental Health Provider
Wraparound
DHS / CWS
School-based Services
Juvenile Justice
DD Services
None
Other
Has the Parent/Caregiver agreed to be contacted by Oregon Family Support Network
*
Yes
No
Is there additional information you would like to share?
Submit
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