The Parenting PATH Referral Form

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Thank you for your interest in The Parenting PATH.

For more information about our agency or our programs, please visit: www.parentingpath.org

Email *

Date

YYYY

Program(s) I am referring to:

** Please check a MAXIMUM of 2 programs per referral**

(For specific program information please click here.)

Family Centered Treatment®

Family Support (Available in Forsyth & Stokes counties, no DSS CPS Involvement)

Family Transitions & Co-Parenting* (fee for service)

Fathers Are Parents Too

GREAT Forsyth (Forsyth Tech Students only)

Knock Out for Change (Forsyth county)

Parent Aide (Forsyth county)

Parent Coaching* (fee for service)

Parent Support (Stokes, Surry counties)

Parent/Teen Solutions (PTS) (Forsyth county)

Parent/Teen Solutions (PTS) (Stokes, Surry counties)

Peaceful Alternatives to Tough Situations (PATTS) (Forsyth county)

Positive Effective Parenting Classes* (fee for service)

Respite Care Services (Forsyth county)

Sexually Reactive Therapy (SOSE Assessment)

Substance Use Navigator

Supervised Visitation and Monitored Exchange* (fee for service)

Trauma-Focused Therapy* (fee for service)

Welcome Baby (Forsyth county)

Required

Name

Agency

Phone

Email Address

Relationship to family

Is there a current signed Release of Information on file?

Yes

Unknown

Clear selection

Has the family been informed of this referral?

(We find that families are more likely to participate if they are expecting our follow-up.)

Yes

Unknown

Clear selection

Check here for challenges the family may be facing:

Interpersonal Violence

Housing Stability

Mental Health

Substance Use

School Behavior

Court Involvement

Parental Supervision

Parental Knowledge

Discipline

Safety

Trauma

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