EmailMe Form - Pregnancy and Parenting Support Referral

PARENT

Parent Name

First Last

Parent Date of Birth

MM / DD / YYYY

Parent DCN:

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

County:

Phone

### - ### - ####

CHILDREN

Child #1 Name

First Last

Child #1 Date of Birth

MM / DD / YYYY

Child #1 Gender

Boy

Girl

Child #1 DCN

Child #2 Name

First Last

Child #2 Date of Birth

MM / DD / YYYY

Child #2 Gender

Boy

Girl

Child #2 DCN

Child #3 Name

First Last

Child #3 Date of Birth

MM / DD / YYYY

Child #3 Gender

Boy

Girl

Child #3 DCN

Child #4 Name

First Last

Child #4 Date of Birth

MM / DD / YYYY

Child #4 Gender

Boy

Girl

Child #4 DCN

Pregnancy Information

Pregnancy Status

Not Pregnant

Pregnant

If pregnant, Estimated Due Date

MM / DD / YYYY

Interested in information about Adoption

Yes

Additional Household Information (check all that apply):

Has household income at or below the 185% poverty level

Has a child less than 2 yrs. of age or is pregnant

“At risk” for physical, emotional, social or educational abuse/neglect

Is involved with the Department of Social Services (Children’s Division)

Has a child in the custody of Children’s Division with an active plan for reunification

Has permanent housing in place

Has transportation

Employed full or part time

Teen Parent

Explanation on why services are being requested/needed:

Referral Source Information

Referral Source Name

First Last

Referral Source Email

Referral Source Agency

Referral Source Phone #

### - ### - ####

N/A (Self-referral)

The family's participation in the parenting program is voluntary. By signing and submitting this form, the family agrees to contact from the LFCS Intake Department.

Parent/Caretaker Signature:

Clear