Referral Program • Spaulding for Children

Do you know someone who could benefit from our program, needs a car seat or even help with diapers? Tell us about that person and we will determine if they are eligible for help!

Date
MM slash DD slash YYYY
Referral Source
Referral Completed By
Client Name
Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Alternate Phone Number
Is Mom Pregnant?
- Yes
- No
If yes, what is the due date?
Trimester?
- 1st
- 2nd
- 3rd
If no, what is the baby's DOB?
MM slash DD slash YYYY
Eligibility
U.S. Citizen:
- Yes
- No
Three (3) or more Risk Factors:
- Yes
- No
Identify Risk Factors
Name and Ages of Minor Children Living in the Home
1. Child's Name
D.O.B.
MM slash DD slash YYYY
2. Child's Name
D.O.B.
MM slash DD slash YYYY
3. Child's Name
D.O.B.
MM slash DD slash YYYY
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Eligibility

Name and Ages of Minor Children Living in the Home

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1. Family History of Child Abuse and/or Neglect
2. Family who is Homeless
3. Parent with Negative or Ambivalent Attitude Regarding Pregnancy or Parenting
4. Parent with a Destructive Temperament who has Unrealistic Expectations of the Child and/or views Harsh Punishment as Appropriate
5. Parent with Substance Abuse or Addiction
6. Child with Long-Term or Chronic Illness
7. Family who is Isolated with Inadequate Support System
8. Parent with Diagnosed Mental/Physical Condition that Interferes with Parenting Ability
9. Family History of Delinquency
10. Teen Parent
11. Family with Incarcerated Parent
12. Child with Diagnosed Handicapped Condition
13. Child with a Diagnosed Mental Health Condition or Documented Behavioral Issue