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STRENGTHENING FAMILIES REFERRAL FORM

This referral form is meant to be used by parents/caretakers interested in enrolling into the Strengthening Families Program, or by professionals referring a family. Youth participants must be between 7 and 17 years old and reside in Forsyth County. At least one parent/guardian is required to participate with their enrolled youth.

The program takes place once per week, typically from 6–8 PM, via Zoom or in-person at Family Services. SFP runs continuously throughout the year. The program is free for Forsyth County residents.

After submitting this form, you will be contacted by the Strengthening Families Program Assistant. If you have questions, please email Courtney Perry, cperry@familyservicesforsyth.org or call (336) 722-8173.

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Parent/Caregiver Name*

First Last

Relation to Youth*

Additional Parent/Caregiver Name

First Last

Relation to Youth

Child's Full Name*

First Middle Last

Child's Age*

Child's Date of Birth*

Are there additional siblings being referred?*

Yes

Not Sure

If there are multiple siblings in the same family being referred, please provide the information for each sibling below. Referrers, it's okay if you don't know the other sibling information.

Second Child's Full Name

First Middle Last

Second Child's Age

Second Child's Date of Birth

Would you like to add another child?

Yes

Third Child's Full Name

First Middle Last

Third Child's Age

Third Child's Date of Birth

Would you like to add another child?

Yes

Fourth Child's Full Name

First Middle Last

Fourth Child's Age

Fourth Child's Date of Birth

Would you like to add another child?

Yes

Fifth Child's Full Name

First Middle Last

Fifth Child's Age

Fifth Child's Date of Birth

Primary Language Spoken in Household*

Address*

Street Address Street Address Line 2 City ZIP/Postal Code

Phone Number*

E-mail Address*

Is child able to participate in a video Zoom call from home?

Yes

Not Sure

Zoom requires an internet-connected computer or the ability to download Zoom on a smartphone.

Which days of the week work well for a 6–8 p.m. meeting?

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Check all that apply.

Why are you interested in the Strengthening Families Program?*

Skip this section if you are a parent or caretaker self-referring your family to the program.

Referrer Name

First Last

Referring Agency, Organization, or Office Name

Phone

Is the client aware you are referring them?

Yes

Not Sure

CAPTCHA

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1200 S. Broad Street
Winston-Salem, NC 27101

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Toll free: (800) 316-5513