Child Abuse and Neglect Prevention Agency Serving Greenville, Pickens, Anderson, Oconee and Spartanburg
1899 Gentry Memorial Highway, Easley, SC 29640
864-898-5583
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HEALTHY FAMILIES FOOTHILLS
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Healthy Families Foothills
Healthy Families Foothills
Healthy Families Foothills Referral Form
Parent Name
*
First
Last
Parent Date of Birth
*
Second Parent Name
First
Last
Second Parent Date of Birth
Parent Phone
*
Parent Alternate Phone
May we leave a message?
*
Yes
No
May we text you?
*
Yes
No
Do you have transportation?
*
Yes
No
Is DSS currently involved?
*
Yes
No
Enter Your Address
*
Street Address
City
State
Zip Code
Are you currently pregnant?
*
Yes
No
Due Date
*
Children's Information
Child 1 Name
First
Last
Age, DOB, grade, where is child 1 currently living?
Child 2 Name
First
Last
Age, DOB, grade, where is child 2 currently living?
Child 3 Name
First
Last
Age, DOB, grade, where is child 3 currently living?
Child 4 Name
First
Last
Age, DOB, grade, where is child 4 currently living?
Current Employment Status
*
Full Time
Part Time
Unemployed
Disabled
Main reason for seeking services
*
Referring Agency
Name of Person Making Referral
*
First
Last
Phone Number of Person Submitting Referral
*
Person Making Referral Email
Marital Status
Married
Single
Separated
Divorced
Widowed
Is partner unemployed? (pertains to spouse or partner who will be involved with mother and baby)
Yes
No
N/A
Inadequate income, according to parent, or no information regarding source of income (e.g., Medicaid, employed without insurance, stated concerns about finances by family)
True
False
Unknown
Unstable housing (no home, uncertain of having home, or questionable address, such as homeless shelter)
True
False
Unknown
No phone
True
False
Unknown
Education under 12 years
True
False
Unknown
Emergency contacts do not include immediate family
True
False
Unknown
History of substance abuse
True
False
Unknown
Late prenatal care (started after the 12th week), no prenatal care, or poor compliance
True
False
Unknown
History of abortions
True
False
Unknown
History of psychiatric care or active psychiatric care
True
False
Unknown
Abortion unsuccessfully sought or attempted for this pregnancy
True
False
Unknown
Adoption sought, attempted, or considered for this pregnancy
True
False
Unknown
Marital or family stresses
True
False
Unknown
History of or current depression
True
False
Unknown
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