Healthy Communities
Partnership
SM
Greater Franklin County
www.hcpfranklinpa.org
phone 717-264-1470; fax 717-504-8966
232 Lincoln Way East, Suite B; Chambersburg, PA 17201
FRANKLIN COUNTY FAMILY GROUP DECISION-MAKING
AGENCY REFERRAL FORM
CONFIDENTIAL
* The FGDM Coordinator/Supervisor will contact you to review the referral information *
Case Name (Family Name):
Referred by:
Phone/Ext.:
Enter office number here.
Other Phone/Ext.: Enter mobile/other number here.
Sup. Office Phone/Ext.:
Enter supervisor’s name here.
Name of Probation Officer:
Probation Phone/Ext.:
Enter officer’s name here.
Court Involved: ☐ Y or ☐ N
Click here to enter a date.
Agency: ☐ JPO | ☐ FCCYS | ☐ Enter other agency here.
Click here to enter referring worker’s name.
Name of Supervisor:
Date:
Click here to enter a case / family name.
Previous Court Date:
Click to enter date.
Fax: Enter fax number here.
Enter sup’s number here.
Enter officer’s number here.
Next Court Date:
Click to enter date.
FAMILY INFORMATION
Key Contact Person:
Address:
Ethnicity
Address
Phone 1
Phone 2
Email
Enter number here.
Email:
City, State Zipcode
Caregiver(s)
Name
DOB/Age
Mother
Phone 2:
Choose or enter relationship.
Enter mobile/other number here.
Ex.: [email protected]
Enter name here.
Enter name here.
Other: Enter/choose relationship.
Enter name here.
Ex.: 01/01/2000
| Age
Choose or enter ethnicity/race.
Enter street address here.
City, State Zipcode
Enter primary number here.
Enter mobile or other number here.
Ex.: [email protected]
Ex.: 01/01/2000
| Age
Choose or enter ethnicity/race.
Enter street address here.
City, State Zipcode
Enter primary number here.
Enter mobile or other number here.
Ex.: [email protected]
Ex.: 01/01/2000
| Age
Choose or enter ethnicity/race.
Enter street address here.
City, State Zipcode
Enter primary number here.
Enter mobile or other number here.
Ex.: [email protected]
Child(ren) Name(s)
Enter name here.
MCI #: Enter MCI # here.
Enter name here.
MCI #: Enter MCI # here.
Enter name here.
MCI #: Enter MCI # here.
Enter name here.
MCI #: Enter MCI # here.
Enter name here.
MCI #:
Phone 1:
Enter street address here.
City/St/Zip:
Relationship to youth:
Click here to enter key contact’s name.
Enter MCI # here.
Race
Choose or
enter race.
Choose or
enter race.
Choose or
enter race.
Choose or
enter race.
Choose or
enter race.
Father
Hisp./Non-hisp.
Choose
ethnicity.
Choose
ethnicity.
Choose
ethnicity.
Choose
ethnicity.
Choose
ethnicity.
Birthdate
Ex.:
01/01/2000
Age / Gender
Age / Gender
Ex.:
01/01/2000
Age / Gender
Ex.:
01/01/2000
Age / Gender
Ex.:
01/01/2000
Age / Gender
Ex.:
01/01/2000
Age / Gender
Lives with…
Enter name here.
Enter name here.
Enter name here.
Enter name here.
Enter name here.
Bringing passionate people together to advance the health and well-being of Franklin County residents.
Have you discussed the practice of FGDM with the family? YES or NO
If No, when are you available to meet with the family and a FGDM
coordinator to discuss the possibility of a family group conference? Click here to enter a date.
Have you and the family completed the Participation Agreement/Authorization of Consent Form? YES or NO
If YES, please return the Participation Agreement/Authorization of Consent along with this Referral Form.
When would you prefer the Family Group Conference to occur? Click here to enter a date.
At the time of the conference, please select the child/youth’s Court/Legal Involvement (select one):
☐
☐
Alleged Dependent
Alleged Delinquent
☐
☐
☐
☐
Dependent
Delinquent
Both (Dependent & Delinquent)
None
Are there any crucial deadlines the FGDM Coordinator should be aware of at this time? Please describe.
Please briefly describe any crucial deadlines in this space.
What is the main purpose or objective for utilizing a family group conference? Please state the main purpose or
objective here.
Please mark all areas that help describe the strengths and the concerns you observe. These will be shared with
the family during the coordination period as well as the conference itself.
Family Strengths:
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Cooperative
Trustworthy
Thoughtful
Hard working
Sense of humor
Talkative
Respectful
Dependable
Integrity / Truthful
Follow Through
Family Concerns:
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Strong Networking
Open Minded
Determined
Motivated
Receptive to Help
Open up to Others
Reliable
Loving to others
Tolerant / Merciful
Other:
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Relationship Issues
Supervision
Neglect
Truancy
Substance abuse
Financial
Physical abuse
Behavior issues
Mental health
Sexual abuse
☐
☐
☐
☐
☐
☐
☐
☐
☐
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Housing
Communication
Anger
Grief / Loss
Trauma
Physical Health
Emotional Health
Support Network
Motivation
Other:
What are the bottom-line concerns that MUST be addressed by the family at the family group conference in
order for you to accept the family’s plan? These are the non-negotiable concerns that address safety,
permanency, and well-being and should guide the stated purpose for the conference.
1. Please describe the most important bottom-line concern here.
2. Please describe the second most important bottom-line concern here.
3. Please describe the third most important bottom-line concern here.
4. Please describe the fourth most important bottom-line concern here.
Briefly describe the situation and any other relevant information that we should know about the family
(custody, POA/Public Defender/Attorney, PFA’s, relational dynamics, restraining orders, culture, heritage,
religious affiliation/ beliefs, transportation needs, disabilities, services in place or needed, etc.)
Please describe other relevant information in this space.
* Save this completed form to your computer or other device. Then attach and send this completed form
along with any scanned or electronic case profiles, other documentation, or other relevant information to
the FGDM Supervisor (Christy Unger – [email protected]).