CPC_Family

Meeting Referral Form - Family Questionnaire
We look forward to partnering with you in support of your child. Please answer all questions and provide as much detail as possible. The more information we have the more program eligibility we can hopefully provide your family. You are welcome to attach additional information and documents you feel would be helpful for the community members to review.
Child & Family Information
Date*

MonthDayYear
Date
Child/Youth Legal Name

First NameLast Name
Child/Youth Date of Birth

MonthDayYear
Date
Child/Youth Preferred Language
Other names your child prefers or is known by
Parent/Guardian Name

First NameLast Name
Parent/Guardian Relationship to Child/Youth
Parent/Guardian Preferred Language
Do you reside in Travis County?*

YESNO
Family Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Primary Phone
Please enter a valid phone number.
Family Email
example@example.com
Does the Child/Youth live in the same home as the Parent/Guardian?

YESNO
Child/Youth Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver at Child/Youth Current Address

First NameLast Name

Meeting Referral Form - Family Questionnaire
We will not be able to serve the Child/Youth through our Travis County CRCG meeting. You can find the CRCG meeting for the child’s county here: Community Resource Coordination Groups (CRCG) (https://crcg.hhs.texas.gov/).

Referral Information
Person Who Referred Family to CRCG-CPC

First NameLast Name
Referral Agency
Referral Contact Phone
Please enter a valid phone number.
Referral Contact Email
example@example.com
Reason for Referral (summary of your Child/Youth behaviors, current needs, concerning events, diagnoses, etc.)
Current services your Child/Youth is receiving, and agencies or organizations involved with your child
Past services your Child/Youth has received, and agencies or organizations previously involved with your child
Are you considering placing your Child/Youth out of the home for treatment or other needs?

YESNO
Reason(s) for considering placing your Child/Youth out of the home for treatment or other needs
Name of school your child currently attends. Who is a good contact person on their campus (please include full name, phone, and email address)?
Is your Child/Youth at risk of not being able to attend the school of your and/or their choice? (placed in an alternative program, suspended due to behaviors, etc.)

YESNO
Reason(s) your Child/Youth is at risk of not being able to attend the school of your and/or their choice.
Do you feel you need help advocating for your Child/Youth with their school?

YESNO
Please share what challenges you are experiencing.
Does your Child/Youth have any medical conditions, physical challenges, intellectual, or developmental delays (include any treatments they receive or have received in the past)?

YESNO
List your Child/Youth medical conditions, physical challenges, intellectual, or developmental delays
What are you Child/Youth strengths?
What are your family’s strengths?
What does your Child/Youth and family enjoy doing together?
What are you as a parent and caregiver doing to take care of yourself?
What additional supports and/or services would you like for yourself as the Child/Youth caregiver?

Household Members
Who lives in the child/youth’s home? (please include relationship to child/youth & age of any children)
Any Parent or Legal Guardian Residing Outside of the Home?

YESNO
Please list any Parent or Legal Guardian Residing Outside of the Home.
Any additional caregivers who often visit in the home or whose home the child/youth stays? (please list name of caregivers and relationship to child/youth)

Meeting Referral Form - Family Questionnaire

Child & Family Information

Meeting Referral Form - Family Questionnaire

Demographic Information

Referral Information

Household Members

Additional Child & Family Information