Referrals

Thank you for your interest in The Family Room and for choosing to partner with us in serving families involved in the child welfare system.

To participate in our expanded, therapeutic, hands-on parenting program, a family has to have an open child welfare case with one or more children in DHS custody. All referrals must be completed and submitted by a designated Child Welfare Representative. If you are a parent, attorney or community service provider, please contact the assigned caseworker about making a referral.

TFR is able to accommodate families with one or more parents who can visit together. If parents must visit separately, TFR can serve one parent at a time.

If you have trouble completing the online referral form, please contact referrals@familyroomoreon.org for assistance.

Thank you!

Step 1 of 7 - Case Location & Details

Case Location & Details
Date:*
MM slash DD slash YYYY
Oregon County*
Branch:*
Case Name:*
Case Number:*
Caseworker:*
First Last
Phone:*
Email:*
Supervisor:*
First Last
Phone:*
Email:*

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Parent
Please provide details for all parents being referred for services.
Parent Name:*
First Last
Gender:*
Prounouns:*
Date of Birth:*
MM slash DD slash YYYY
Ethnicity*
- White
- Hispanic or Latino
- Black or African American
- Native American or American Islander
- Asian/Pacific Islander
- Other
Address*
Street Address Address Line 2 City State ZIP Code
Phone:*
Alt Phone:
Email:*
Attorney Name:
First Last Suffix
Are there any children currently living in the home with this parent who are not in substitute care?*
- Yes
- No
Child Information:
Name Gender Date of Birth

Please click the + button to add additional children.
Additional Parent(s)
Parent Name: Phone: Email: Actions

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Parent Name:	Phone:	Email:	Actions
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Child Details
Please provide details for all children being referred for services
Name
First Last
Sex:*
Prounouns:*
Date of Birth:*
MM slash DD slash YYYY
Ethnicity*
White
Hispanic or Latino
Black or African American
Native American or American Islander
Asian/Pacific Islander
Other
Date of Removal from Parents:*
MM slash DD slash YYYY
Attorney:*
First Last Suffix
Briefly describe the children level of functioning (include developmental, medical, and any food allergies.*
Any Challenges with Sibling Interactions?*
Yes
No
Details:
Child's Parent(s)
ADD Parents: Parent's Name: Actions

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Delete
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Child(ren) Details
Name Sex: Prounouns: Date of Birth: Actions

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ADD Parents:	Parent's Name:	Actions
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Foster Parent Details
Please provide details for the foster parent(s). If there is more than one foster home associated with this family, please add them.
Foster Parent(s) Name:*
First Last Suffix
Foster Parent(s) Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Foster Parents Phone:*
Alt Phone:
Foster Parent Email:*
Alt Email:
Name of child(ren) in home:

Please click the + button to add additional foster home
Add Additional Foster Home
Foster Parent(s) Name: Foster Parent(s) Address: Foster Parents Phone: Actions

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Foster Parent(s) Name:	Foster Parent(s) Address:	Foster Parents Phone:	Actions
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History & Details
Current Case Plan*
Date of Next Court Hearing:*
MM slash DD slash YYYY
Type of Next Hearing*
Is there a Court Appointed Spacial Advocate (CASA) Assigned?*
Yes
No
Name:
First Last
Phone:
Email:
Is this an ICWA Case?
Yes
No
Tribe:
Child Enrolled:
First Last
Contact Name:
First Last
Phone
Email:
Reason for Removal: Please provide a detailed account of why the child(ren) were removed from the home.*

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Services:
Services Please provide details as to the current or referred services for each family member.
SERVICES PARENT(S) ARE INVOLVED IN:
Parent Name Type of Service Service Provider

Please click the + button to additional service.
SERVICES CHILD(REN) IS INVOLVED IN:
Child Name Type of Service Service Provider

Please click the + button to additional service.
Briefly Describe Each Parent's Motivation To Parent Their Child(REN):

Please click the + button to add an additional parent.
Visitation
Are visits currently happening for the family?
Yes
No
Type of Visitation*
In addition to the listed Parent(s) and Child(ren), are any other individuals approved to attend visitation sessions?*
Yes
No
List Additional Approved Individuals:
Name Relationship to Child
Current Visitation Schedule for Parents:*
Day of the Week: Time: Which Parent: Type of Visitation:

Please click the + button to add additional days/times.
Any Additional Information?

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Parent Release of Information
Parent Release of Information:*
Drop files here or
Accepted file types: jpg, pdf, doc, docx, png, Max. file size: 300 MB.
In addition to releases of information for each parent referred, please upload any necessary or helpful documents for TFR (ie: ROIs, visit notes, assessments, evaluations, meeting notes, etc.
Drop files here or
Accepted file types: jpg, doc, docx, pdf, png, Max. file size: 300 MB.
TFR POLICIES AND PROCEDURES*
SELECTING AGREE INDICATES ACKNOWLEDGEMENT OF THESE POLICIES AND PROCEDURES AND IS REQUIRED FOR SERVICE RECEIPT AT THE FAMILY ROOM.
TFR is a community resource offered to DHS involved families. All policies and procedures are determined by TFR. Please refer to signed MOUs for additional details.

TFR offers a professional service and is staffed by educated, experienced, and trained social workers. Our program is a registered 501(c)(3) non-profit organization and carries adequate and appropriate liability insurance.

Requesting visitation at TFR automatically grants our program with the authority to determine logistical details relevant to the implementation of each individual visit, including but not limited to the transportation of children before, during, and after each visit as well as the specific TFR location for each visit. The safety and well-being of each individual family, as well as the program as a whole, is foundational when determining logistical details, whether proactively in advance of each visit or urgently as unforeseen challenges arise within each visit. Safety concerns can be discussed with TFR staff on a case-by-case basis.

DHS is expected to notify TFR staff 24 hours prior to a scheduled visit in the event of a visit cancellation. A visit will not be considered canceled until DHS receives written or verbal acknowledgment of the cancellation from TFR staff. TFR will notify DHS via email in advance of any necessary cancellations, i.e. due to inclement weather, sick children, or unavailable parents. TFR generally follows DHS’s inclement weather policies.

DHS caseworkers are welcome to visit their families during their visits at TFR. To ensure a safe and trauma-informed visitation environment, we expect advance notice of each caseworker visit and that caseworkers refrain from discussing case information while at TFR. Caseworkers are welcome to have case planning conversations with their clients after TFR visits off-site of our program.

TFR will refuse any attempts to serve legal papers to parents visiting our program.

DHS must notify TFR of any active warrants for an enrolled parent. Any parent with an active warrant is not permitted to attend a visitation at TFR.

Any persons other than the approved birth parent(s), i.e. CASA’s, relatives, or service providers, need to be approved in advance of each visit by DHS. Additional visitors are not considered approved to visit until DHS receives written or verbal acknowledgment of the request from TFR staff.
Name
This field is for validation purposes and should be left unchanged.

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Name	Gender	Date of Birth

Parent Name	Type of Service	Service Provider

Child Name	Type of Service	Service Provider

Name	Relationship to Child

Referrals

Step 1 of 7 - Case Location & Details

Case Location & Details

Parent

Child Details

Foster Parent Details

History & Details

Services:

Visitation

Parent Release of Information

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