Community & Family Connections Referral Form
The Jeffco Schools Medicaid program and the Homeless Service program have merged together. We continue to assist families living in transition (homeless) as well as assist families applying for Medicaid/CHP+ and provided resources for other medical concerns. With this merge we have divided the articulation areas (High Schools and the schools that feed into them) between the 4 team members. You will see our contact information below in the CFC Liaison selection.
Name of Person Submitting Referral *
Your answer
Parent/Guardian Name *
if not staying with legal parent or guardian (unaccompanied youth) please type N/A.
Your answer
Parent/Guardian Contact/Phone Number *
If you do not have a phone number, please type N/A.
Your answer
Referral's Contact/Phone Number *
Your answer
Language Spoken at Home
Your answer
Jeffco Schools CFC Liaison
Housing Situation *
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