CRCG_Family

Meeting Referral Form - Family Questionnaire

This questionnaire is for the parent or primary caregiver to complete in their own words.
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.
Child & Family Information
Date

MonthDayYear
Date
Child/Youth Legal Name

First NameLast Name
Please share any names your child prefers or is known by:
Child/Youth Date of Birth

MonthDayYear
Date
Child/Youth Preferred Language
Parent/Guardian Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Family Email Address
example@example.com
Does the Child/Youth live in the same home as the Parent/Guardian?
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

First NameLast Name
Referral Agency
Referral Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referral Contact Email
example@example.com
Reason for Referral (summary of your child's behaviors, current needs, concerning events, diagnoses, etc.)
Current services your child is receiving, and agencies or organizations involved with your child
Past services, agencies, or organizational support your child has previously received
Are you considering placing your child out of the home for treatment or other needs?
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.)
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 with their school?
Please share what challenges you are experiencing.
Does your child have any medical conditions, physical challenges, intellectual, or developmental delays (include any treatments they receive or have received in the past)?
List your Child/Youth medical conditions, physical challenges, intellectual, or developmental delays
What are you child's strengths?
What are your family’s strengths?
What does your child 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's caregiver?

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