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Referral Form
Is this referral for your own family or someone else?
(Required)
My Family
Someone Else
Referring Person's Name
(Required)
First
Last
Referring Organization
Referring Person's Phone Number
Referring Person's Email
(Required)
Enter Email
Confirm Email
If the referral is on behalf of someone else, have they expressed interest in working with Back2Back?
Yes
No
Name of Household Primary Caregiver
(Required)
First
Last
Phone of Primary Caregiver
(Required)
Name of child(ren), age(s), and school(s) in the household?
(Required)
Child Name
Age
School
Add
Remove
What neighborhood does the family live in?
(Required)
What is the family's primary language?
(Required)
Briefly describe the challenges the family needs assistance with:
(Required)
Are any youth in the home involved with the juvenile court system?
(Required)
Yes
No
Unknown
Are there any other organizations the family is connected to?
(Required)
Yes
No
Unknown
What organizations and services are being utilized by the family?
(Required)
Name of Organization
Services Utilized by Family
Add
Remove
Next Steps
Thank you for making a referral. Back2Back Cincinnati engages with the whole family. Thus it is important that families we come alongside are invested in the process and have a voice in their stories. There are times Back2Back Cincinnati is not the right fit for families, so making a referral does not guarantee Back2Back Cincinnati will be able to assist the family. However, Back2Back Cincinnati staff reach out to everyone who submits a referral to talk through next steps in the referral process.
Sponsor A Child or Family
Release of Information
Name of Participant
(Required)
First
Last
Release of Information (ROI) Consent
I understand my student’s story and/or my story is ours to share. I understand Back2Back Cincinnati will hold our information confidential unless necessary by law. I realize Back2Back Cincinnati can better serve my student and/or our family when they communicate to other individuals working with my student and/or our family. I give permission for Back2Back Cincinnati to give and receive information in regards to my student(s) and/or myself from Hamilton County Juvenile Detention Center (20/20), Hamilton County Juvenile Probation, Hamilton County Public Defender’s Office, Hamilton County Diversion Court Programs, Hamilton Prosecutor’s Office, and Hamilton County Juvenile Court.
Consent
(Required)
I CONSENT to the release of information.
Name of Consenting Guardian or Student (if over 18)
(Required)
Submitting your name below as a digital signature, you are acknowledging any release of information and understand that the permission can be revoked at any time by contacting Back2Back Cincinnati in written format either in email or letter.
First
Last
Date
(Required)
Provide the date of consent and submission of this form.
MM slash DD slash YYYY
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