Strong Fathers Referral Form (Durham)
This form is to be completed by the social worker, judge, attorney, or other professional referring a potential participant to the Strong Fathers program.
Is this referral part of a court order? *
If applicable, is this referral part of the father's DSS service plan? *
About the Person Making the Referral
Name *
Your answer
Telephone number *
Your answer
Email address *
Your answer
Organization/Job Title/Unit *
Your answer
About the Father Being Referred
Name of father
Your answer
If applicable, please indicate how this father is involved with DSS *
Check all that apply and feel free to add comments.
Required
Comments related to above:
Your answer
Why are you referring this person to Strong Fathers? *
Your answer
Father's DOB *
MM
/
DD
/
YYYY
Father's Race *
Street Address *
Include apartment #
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Home
Your answer
Phone Number
Work
Your answer
Who does the father live with? *
(i.e. alone, with current partner, with one or more children, with other extended family)?
Your answer
Please tell us about this father's parenting history. *
What is this father's history of parenting his or another's child?
Your answer
Have there ever been allegations or substantiations of child sexual abuse against this father? *
If you answered "yes" above, please provide additional information regarding the allegation(s) or substantiation(s)
Your answer
Is the father being referred a veteran *
About the Father's History of Domestic Violence (Emotional/Physical Abuse Against a Partner)
Briefly describe the most recent act of abuse and identify when this incident occurred and against whom *
Your answer
Briefly describe the most serious act of abuse and identify when this incident occurred and against whom *
Your answer
In your opinion how serious is the pattern of abuse? *
Not at all serious
Extremely serious
Whom has this person abused? *
Check all that apply
Required
About The Father's Other Service Plan Goals
Please briefly describe the father's other service plan goals. *
Your answer
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