SCA Fatherhood Engagement Program Youth Referral Form

SCA Fatherhood Engagement Program Youth Referral Form

This is the referral form used to make referrals to SEI's Community and Family Programs Second Chance Act Fatherhood Engagement program. Referrals can be made by an ODHS Caseworker or Family Coach, a Community Agency, a community member, or by self-referral. You will need to upload a signed ROI for you/your agency to share information with SEI.

Eligibility criteria:

Youth must have a current or formerly incarcerated African American father.
Youth must under the age of 18 years old.
Youth must be willing to participate in services.

Services provided:

The goal of this program is to improve the relationship between the youth and their currently or formerly incarcerated parent. We also aim to increase the youth's self-esteem, positive behaviors, and school attendance, while stabilizing the youth's current placement.

Once this referral is submitted, someone from the team will contact you within two business days.

If you have questions, please contact SEI Child Welfare Advocacy Programs Manager, Ja'Nelle Samuels at CWAreferrals@selfenhancement.org or at (971) 225-3416.

Date*

Date of the referral.

Youth Information

Youth's Name*

Youth's DOB*

Youth's Pronouns*

Youth's Phone Number

Phone

Youth's Current Address*

Youth's Email Address

Is there an open child welfare case?*

Select

If yes, please list the Caseworker's contact info.

Please list the Caseworker's name, phone number, and email address.

Parent's Information

Parent #1 Name*

Please enter the incarcerated/formerly incarcerated parent's information here.

Parent #1 Phone Number*

Phone

Parent #1 Address*

Parent #1 Email Address

Parent #2 Name

Please enter the other parent's information here.

Parent #2 Phone Number

Phone

Parent #2 Address

Parent #2 Email Address

Placement Name

Please enter the name of the person the youth is living with, if different than Parent #1 or #2.

Placement Phone Number

Phone

Placement Email Address

Referrer's Name*

Please enter your name here.

Referring Agency Name*

Referrer's Phone Number*

Phone

Referrer's Email Address*

Brief Summary of Youth's Current Status:*

Background summary and summary of current status.

Status of Parent/Youth Relationship?*

Does the youth have a relationship with their formerly incarcerated parent?

Is the youth participating in any other services?*

Select

If yes, which services?

Please upload a signed ROI.*

Please upload a signed Release of Information (ROI) that allows you/your agency to share information with SEI.

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.