DHRD EFHV Referral-Form

DHRD Referral-Form

We are the Early Foundations Home Visiting Team. The program serves prenatal up to five years old. We serve Native American families who reside within the boundaries of CSKT, 1st gen. descendants of CSKT, along with other federally recognized tribes. We support a range of people including first time parents, at risk families, and grandparents who care for the target child. Our team uses an evidenced-based curriculum, Parents as Teachers, in every home visit. The program provides child development screenings, along with fun activities to engage the whole family. Our program seeks to improve maternal and newborn health, along with educating parents with positive parenting tips, home safety, school readiness, and help connect families with other local resources and supports. Our program is completely voluntary and free of charge.

Family Information

Mother's Name:(Required)

Tribal Affilication:(Required)

Descendant:(Required)

Yes

DOB:

Father's Name:(Required)

Tribal Affilication:(Required)

Descendant:(Required)

Yes

DOB:(Required)

Mailing Address(Required)

Street Address Physical Address City State ZIP Code

Email(Required)

Phone(Required)

Child Name:(Required)

DOB:(Required)

Tribal Affilication:(Required)

Referred By

Name:

Phone:

Company:

Referral Date:

Reason for Referral:

Is this a self-referral:(Required)

If other who is the Social Worker?

Yes

Other

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