Part 1: Information about the Referral Source
Please provide some information about the referral agency:
If You Selected “Other” Please Explain:
Name of Person Making Referral:
Part 4: Eligibility to Participate
Please answer a few questions so that we can determine if your family is eligible to receive services from SafeCare Colorado
Is there a child age 5 or younger living in the home?*
We recognize that this information is private and sensitive, and it will be kept strictly confidential. The information will not be shared in any way beyond determining your eligibility. We need to ask this question to confirm if your family is eligible to participate in SafeCare Colorado.
Please select all characteristics that apply to your family. Hold down the “Ctrl” key to select more than one.*
Part 5: SafeCare Colorado Release of Information
This section is optional
I hereby authorize the person, agency, or institution entered below to supply information requested by SafeCare Colorado, including relevant health information and results of assessments and consultations. I release the person, agency, or institution from any and all liability for supplying such information.
I also authorize SafeCare Colorado to supply information obtained directly from me, or from any person, agency, or institution which has provided information to SafeCare Colorado about me, to the person, agency, or institution entered below. I release SafeCare Colorado from any and all liability for supplying such information.
Printed name of person, agency, or institution:
This authorization is given only in connection with its use by SafeCare Colorado in its administration of services and for no other purpose. I certify this request has been made voluntarily and that the information given above is accurate. I understand that this consent may be revoked at any time, with the exception that disclosure of information has already occurred prior to the receipt of the revocation by the above named provider. If written revocation is not received, the authorization will be considered valid for a period of time not to exceed 1 year from the date of signing.
By checking this box, I am agreeing to the above terms.
Date:[ 10/28/2021 ]
Verbal Consent Received?
Referral Signature Date:[ 10/28/2021 ]