Family Stability Referral Form

We encourage you to review Quick Facts with the family as you, together, fill out the referral form and release of information below. If you have any questions, please do not hesitate to contact Traci Schwartz-Sullivan at 937-327-1793. Access a copy of the "release of information" form.

Planning Process
It is the responsibility of the Referral Source who will act as the family team leader to invite the custodian/family/caretaker to the staffing as well as providers who have or are currently working with the family. The family is encouraged to bring supportive extended family and friends. Everyone is invited to contribute to understanding the strengths, needs and culture of the family and to participate in the planning process.

Gathering & Reviewing Information
By submitting this request, the Referral Source certifies that he/she has gathered and reviewed the information below with the parent(s), custodian or primary caretaker unless noted below. The completed referral form will be reviewed by the committee prior to the staffing. If the family did not engage in the information gathering process, but will attend the staffing, please fill out the domains as best you can. A copy of the referral will be given to the family at the start of the meeting.

Please note that because of the nature of the committee, some family history may already be known due to past or current involvement with a specific Agency. This information may be addressed, despite it not being listed as a concern/issue or strength by the family.