SCA Fatherhood Engagement Program Re-entry Referral Form

SCA Fatherhood Engagement Program Re-entry Referral Form

This is the referral form used to make referrals to SEI's Child Welfare Advocacy Second Chance Act Fatherhood Engagement program.

*A signed ROI is needed to proceed with this referral.*

Eligibility criteria:

Referral must be made by Multnomah County Parole & Probation, an ODHS Caseworker, a Community Agency, or via in-house referral through SEI.
Fathers must identify as African-American and have self-reported or child-identified parental responsibility for a minor child through biological, legal, or ongoing parental relationship.
Must be re-entering, or have re-entered in the past 18 months to Multnomah County.
Must have at least one child. Child is defined as the biological child of a father, or a child to whom the re-entering father has played a father role to.
Must be willing to participate in re-entry case management services and sign an agreement stating so.

Services provided:

The goal of this program is to improve the relationship between the African American father and his children. We also aim to increase the father's parenting skills.

Services include case management, connection to long-term community resources, system navigation.

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 of Referral*

Father's Full Name*

Father's Date of Birth*

Father's Phone Number*

Father's Email Address*

Father's Address*

Please enter the father's full address, including city, state, and zip code.

Father's Release Date*

Is there an open child welfare case?*

Select

If yes, please enter the Caseworker's contact info*

Probation/Parole Officer's Name*

Probation/Parole Officer's Phone Number*

Probation/Parole Officer's Email Address*

Probation/Parole Officer's Address*

Referrer's Name*

Please enter your information, if different from Probation/Parole Officer.

Referrer's Agency*

Referrer's Phone Number*

Phone

Referrer's Email Addresss*

Brief Summary of Father's Current Status:*

Does father have a relationship with their child?*

Select

If yes, please enter the child(ren)'s name(s).*

Please attach a signed ROI.*

Please attach a signed Release of Information (ROI) allowing information sharing between SEI and the agency you work for.

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