Circle of Care, Inc. Parent to Parent - Parent Referral

Circle of Care, Inc. Parent to Parent - Parent Referral

Do you know of a parent needing help navigating the child welfare system? A mentor is an individual who has lived experience who can assist you with your DHS case. If you would like a mentor to guide you through the process, please complete this referral form.

Instructions

Please complete one referral per parent. If you have any questions, please email parenttoparent@circleofcare.org. The mailbox is check daily.

Today's date*

Who is making the referral?*

Self

DHS

CASA

Attorney

Transitional Living Program

Rehabilitation Program

Mental Health Service Provider

Parenting Class Provider

Counseling Provider

Other

Parent's Demographic Information

Parent's Name (Last,First)*

Sex*

Select or enter value

Marital Status*

Select or enter value

Ethnicity *

Select or enter value

Language*

Select or enter value

Parent's Contact Information

Address*

Street, City, State, Zip

Contact Number*

Phone

Email Address*

If parent does not have an email address, please write noemail.com

Parent's Case Information

Information related to DHS case

Parent Client ID:*

KK #*

Number of children in referral*

Date Children were Removed*

County of Removal*

The county where you attend court concerning the DHS case. If county is not found, P2P Program does not serve the county.

Adair

Atoka

Bryan

Carter

Cherokee

Choctaw

Coal

Craig

Creek

Delaware

Haskell

Hughes

Johnston

Latimer

LeFlore

Love

Mayes

McCurtain

McIntosh

Murray

Muskogee

Nowata

Okfuskee

Okmulgee

Osage

Ottawa

Pawnee

Pittsburg

Pontotoc

Pushmataha

Rogers

Seminole

Sequoyah

Tulsa

Wagoner

Washington

Primary Concerns*

Reason for involvement with DHS

Physical Abuse

Sexual Abuse

Neglectful Supervision

Physical Neglect

Secondary Concerns*

Exposure to parent's abuse of drugs/alcohol

Exposure to domestic violence

Failure to protect

Inadequate or dangerous shelter/housing

Lack of supervision

Failure to obtain medical attention

Mental health of child

Mental health of parent

Other

Has an Individualized Service Plan been completed?*

Select or enter value

If no, when will it be completed?*

Write date & time

If yes, write the primary goals.*

List at least 3 goals

Next Court Date*

Date & Time

Type of hearing?*

Judge*

Next Family Team Meeting*

Date & Time

DHS Staff Information

District #*

The district the child welfare case in.

Select or enter value

Region #*

The region the child welfare case in.

Select or enter value

Permanency Worker's Name (Last, First)*

Permanency Worker's Phone #*

Phone

Permanency Worker's Email Adress*

Permanency Supervisor's Name (Last, First)*

Permanency Supervisor's Phone #*

Phone

Permanency Supervisor's Email*

Referring Information

Immediate Services

What are the immediate resources and/or services the parent needs?

Reason for a Mentor

Why do you believe this parent would benefit from having a Parent Mentor?

Send me a copy of my responses

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