Part 1: Information about the Referral Source

Please provide some information about the referral agency:

Referral Agency:   

Agency Type:    Child Welfare Community Centers (e.g. YMCA, B&G Club) DHS-Other (e.g. TANF, Judicial/Probation) Early Childhood Councils Early Childhood Education/Child Care Early Intervention Family Resource Center Medical Provider Mental Health Other Home Visitation Program (e.g. Bright Beginnings, PAT, NFP) Public Health (WIC) Substance Treatment Other ECMH Specialist State Support Line Website ECMH Consultant Online Support Line

If You Selected “Other” Please Explain:  

Name of Person Making Referral:   

Phone Number:   

Email Address:   

Part 2: Parent / Caregiver Information

Please provide information for the primary parent or caregiver who will receive services from SafeCare Colorado:

First Name :*   

Last Name :*   

Date of Birth:*   

Gender:*   

Primary Language:*         

Home Address:   

City:   

Zip:   

County:*
--None-- Cheyenne Rio Blanco Mineral Moffat Montezuma Morgan Otero Phillips Prowers Pueblo Rio Grande Routt Saguache San Juan Sedgwick Southern Ute Tribe Ute Mountain Ute Tribe Washington Weld Yuma Conejos Costilla Archuleta Baca Bent Chaffee Crowley Custer Denver Dolores El Paso Huerfano Jefferson Kiowa La Plata Larimer Las Animas Logan Mesa Adams Alamosa Arapahoe

Home Phone:   

Cell Phone:   

Email Address:   

OK to leave a message on voicemail?

OK to text?

Where did you hear about SafeCare Colorado?*

Part 3: Child Information

Please provide information for the child, age five or under, who will primarily receive services from SafeCare Colorado

First Name:   

Last Name:   

Date of Birth:   [ 4/19/2024 ]

Gender:   --None--Male Female Other Unknown Nonbinary

Primary Language:   --None--English Spanish Other American Sign Language (ASL) Amharic Arabic Armenian Cambodian Cantonese Chinese English Sign Language (ESL) Farsi French German Greek Guamanian Haitian-Creole Hawaiian Hebrew Hindi Hmong Hungarian Ilocano Indonesian Italian Japanese Korean Lao Mandarin Mien Other Non-English Polish Polynesian Portuguese Romany Rumanian Russian Samoan Scandinavian Somalia/Somalian Dialect Tagalog Thai Turkish Vietnamese Yiddish Yugoslavian      

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.*

Past contact with child welfare Child has Special Needs Childhood Abuse or Neglect Housing instability/homelessness Less than high school education More than one child under age 5 Receives public assistance Single Parent Stepfather/unrelated male in home Substance Abuse Violence Parent/caregiver under age 20 Mental Health

Comments/Additional Information

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.

Client Name:

Date:[ 4/19/2024 ]

Verbal Consent Received?

Referral Signature:

Referral Signature Date:[ 4/19/2024 ]