Council for Union County Families Referral
Council for Union County Families (CUCF) provides assistance to youth ages 0-21 that are Union County residents. This form is for families to self refer or for service providers to refer families to CUCF for Service Coordination and/or the Wraparound Process. You should expect to hear from CUCF about 10 business days after you fill out this form. Please contact Jason King at 937-738-9800,
or Tisha McCreary at 937-738-9800,
if you have any questions.
Date of Referral
Name of Youth/Family
DOB and Age of Youth
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Declined to Specify
Family Phone Contact
Please list all household members and their relationship to the youth.
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This form was created inside of Mental Health Recovery Board Union County.