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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CLASSES
COUNSELING
HEALTHY FAMILIES FOOTHILLS
GET INVOLVED
DONATE
VOLUNTEER
EVENTS
ABOUT
GALLERY
OUR TEAM
CONTACT
REFERRAL
DONATE
Healthy Families Foothills
Healthy Families Foothills
Healthy Families Foothills Referral Form
Parent Name
*
First
Last
Parent Date of Birth
*
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Second Parent Name
*
First
Last
Second Parent Date of Birth
*
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02
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1942
1941
1940
year
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
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Are you currently pregnant?
*
Yes
No
Due Date
*
01
02
03
04
05
06
07
08
09
10
11
12
13
14
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25
26
27
28
29
30
31
day
/
January
February
March
April
May
June
July
August
September
October
November
December
month
/
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
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1981
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year
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
Please elaborate on any mental health diagnoses
*
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
History of miscarriages
True
False
Unknown
History of psychiatric care
True
False
Unknown
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