JEFFERSON COUNTY FAMILY & CHILDREN FIRST COUNCIL ENGAGE SERVICES

REFERRAL FOR SERVICE COORDINATION

Submit Form To: Family and Children First Council, c/o Jefferson County Education Service Center 2023 Sunset Blvd., Steubenville, OH 43952 Or contact:
Linda Trushel- Supervisor	Email: ltrushel@jcesc.org	Phone: 740-491-0548	FAX: 740-792-4005

From/Name: ___________________________________________Date: _____________________

Affiliation: _______________________________Phone#: ________________FAX: _______________

Affiliation Address: ______________________________________Email: _______________________

Name of child being referred: __________________________________ DOB: _________ Sex: _______

Race: ______ Current Grade in School: ______ Name of School Attending: _______________________

Reason for referral for Service Coordination (Eg: Service Coordination, Mentor, Respite, etc): _____________________________________________________________________________________ _____________________________________________________________________________________ Diagnosis, if any: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Child lives with:	Mother	Father	Other (Please provide contact information below): Name of Parent and/or Legal Guardian: _______________________________Phone: ______________ Address: _____________________________________________________________________________

Parent and/or Legal Guardian agrees by signature and/or verbal consent that Jefferson County Family and Children First Council will be sent a referral for Service Coordination services. Parent and/or Legal Guardian have also been notified that they will be contacted by the Service Coordinator:

X__________________________________________________________________________________ Parent/Guardian Signature and/or Verbal Consent	Date

OFFICE USE-TO BE COMPLETED BY SERVICE COORDINATOR:

Date Referral received by SC: ________________ Date Reviewed by SC: _________________

Date Family Contacted: _______________	Family Assessment Completed on: _________

Eligible Yes	No	1st Team Meeting Date: __________________ Fidelity Case #_____________

Level of Service:	Level One Level Two	Respite Referral (Form attached from JCBDD)

Updated form 3/2024 by PLM