Road to Resilience Program Confidential Referral Form

Road to Resilience Program Confidential Referral Form

Email completed form to: (encrypted) RTRReferrals@ccrcca.org OR call (760)245-0770 ext. 4510 for assistance to complete form.
Referrals are accepted for any pregnant and/or parenting individuals who meet at least one criterion in the “Circumstances Needing Referral” box below*

Receiving CalWORKsPregnantFirst-time PregnancyParenting a child(ren) ages 0-kindergarten age.
Pregnant, if so EDD:
Parenting a child(ren) ages 0-kindergarten age. If so, child(ren)'s ages:
Child 1 DOB:
Child 2 DOB:
Optional: RTR preference, if eligible:

Healthy Families America (HFA)Nurse-Family Partnership (NFP)Parents As Teachers (PAT)
Is there any circumstance that qualifies referral for Doula Support Service?

YesNo
Date*

MonthDayYear
Date
Person making referral:*
Title*
Is pregnancy know to family? (CONFIDENTIAL)*

YesNo
Agency Name*
Email Address*
example@example.com
Phone*
Cell Phone*
Name of Client*
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Address*

Home Address

Street Address Line 2

CityState / Province

Zip Code
Cell Phone*
Home Phone
Other
Preferred Language*
Race/Ethnicity*
English speaking?*

YesNo
Veteran?*

YesNo
Receiving Medi-Cal (MC):*

YesNo
MC#:
If no, is client Medi-Cal eligible?

YesNo
Circumstances Needing Referrals: (Current OR History - Check ALL that apply)

Mental health condition/diagnosisMaternal depression/anxietyInvolvement with DCFSSubstance useEntry into juvenile justice systemEntry into criminal justice systemAdult and/or children with support needsMedical diagnosis/complexityHousing instabilityExposed to trauma/violence/abuseLess than HS education or GEDPrevious pre-term birth (Less than 37 weeks)Previous low birthweight baby (Less than 5lb, 8oz)Unsafe physical living conditions19 years old or youngerFoster care systemStressed FamilyNo Support SystemIPV/DVOther
Adult and/or children with support needs: Pls. Specify:
Unsafe physical living conditions: Pls. Specify
RELEASE AUTHORIZATION
I give permission to representatives of CCRC Road To Resilience, The Office of Child Abuse Prevention and its contracted agencies to contact me regarding enrollment into one of its Road To Resilience Programs. I have been informed and do understand that CCRC RTR representatives, its contracted agencies, and/or their contracted data administrators may use information on this form solely to determine prospective eligibility for services and assist in quality improvement and assurance of services provided through this referral process. I further understand that the data will be kept securely for seven (7) years, in compliance of HIPAA guidelines, whether I accept or decline services.

I have also been informed that should I have questions related to this release authorization and/or CCRC policies relating to data safety, I may contact RTRReferrals@ccrcca.org or call at (760) 245-0770 ext. 4510 for privacy practices can be reviewed at https://www.ccrcca.org/privacy-policy/
Client consented to be referred to home visiting programs. Signature

Clear
or

Verbal
Comments
Road To Resilience Main Office: 15456 W Sage St Victorville, CA 92392 Phone: (760) 245-0770 ext. 4510
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Road to Resilience Program Confidential Referral Form

RELEASE AUTHORIZATION