Moms Matter Referral Form
Peer Support Group to focus moms on their reunification plan:

Moms Matter Overview
When children are removed, many parents enter into shock. The pain is intense. Each parent wants their child back.
Some parents get angry, others depressed, some stay in denial, others start quickly on their Reunification Plan.
For moms, a free, peer support group is available from a community partner.

Groups meet weekly, during a week day, on the bus line. A trained facilitator guides the discussion and encourages each participant to break down treatment plan goals into smaller tasks.

All moms want their children back. The program “Moms Matter” can help.

The Process
1. Moms Matter is offered early on, often during a Family Group Conference, or later, as a mom prepares for reunification.
2. If Mom shows interest, this form is filled out and submitted. The Social Service case worker is asked to approve.
3. A Moms Matter facilitator contacts the mom within 3 days, to discuss the opportunity.
4. Social Services is given a simple, weekly summary:
a. Does Mom come regularly? Is she on time?
b. Is Mom participating?
Your Name *
Your answer
Your Email *
Your answer
Information for Referral
Social Service County *
If you selected "Other" (above), please type name of County:
Your answer
Placement of Children *
Social Service Case Worker Name *
Your answer
Social Service Case Worker Email *
Your answer
Social Service Supervisor Name *
Your answer
Social Service Supervisor Email *
Your answer
Family Group Conference Coordinator Name
Your answer
Family Group Conference Coordinator Email
Your answer
Guardian Ad Litem - Name & Email
Your answer
Guardian Ad Litem Supervisor - Name & Email
Your answer
Mom you are Referring:
First Name *
Your answer
Last Name *
Your answer
Mom's Email
Your answer
Mom's Phone Number *
Your answer
What is the best time to call Mom? *
Your answer
Per Mom, why was her child removed? *
Your answer
What does Mom struggle with? Why does Mom want support and encouragement from others? *
Your answer
Submit
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