01. Family Interest

02. School/Agency Contact

03. Family Info

04. Referral

School/Agency Referral Form

Family Nav

Determining Family Interest in Family Navigation

Is the family interested in the Family Navigation program at EnCompass?

Yes, I personally spoke with the family and they are interested in Family Navigation.

Yes, a colleague personally spoke with the family and they are interested in Family Navigation.

No, we have not determined if the family is interested in the Family Navigation Program.

We ask that you determine whether the family is interested in the Family Navigation program before referring them. Once a family demonstrates interest the rest of the referral form can be completed.

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01. Family Interest

02. School/Agency Contact

03. Family Info

04. Referral

School/Agency Referral Form

Family Nav

Contact People at School/Agency

Your Name

Title

School/Agency

Email Address

Phone Number

Colleague Who Spoke to Family

Title

School/Agency

Email Address

Phone Number

List any other service providers and contact info (teachers, counselors, social workers, etc.) at your school/agency who can be contacted concerning the family:

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01. Family Interest

02. School/Agency Contact

03. Family Info

04. Referral

School/Agency Referral Form

Family Nav

Family Home Address

Family Address

Parents/Guardians

Parent/Guardian 1

Relationship to children

Parent/Guardian 1

Mother

Father

Other:

Preferred Language

Parent Guardian 1

English

Spanish

Other:

Primary Phone

Parent/Guardian 1

Secondary Phone

Parent/Guardian 1

Parent/Guardian Email

Parent/Guardian 1

Is there at 2nd parent/guardian?

Yes

No

Parent/Guardian 2

Relationship to children

Parent/Guardian 2

Mother

Father

Other:

Preferred Language

Parent/Guardian 2

English

Spanish

Other:

Primary Phone

Parent/Guardian 2

Secondary Phone

Parent/Guardian 2

Parent/Guardian Email

Parent/Guardian 2

Children in the Family

How many children are in the family (if known)? Enter the number of children by age group in the boxes below:

Age 0-4

Age 5-8

Age 9-12

Age 13-15

Age 16-18

Please enter the student you are referring below. If you have information on other siblings in the family, click "add another child" to add sibling information.

Child's Name

DOB

MM

/

DD

/

YYYY

Gender

Male

Female

Other:

Please select

School

School ID

School Attendance %

Check any support services child receives:

IEP

504 Plan

ESL

Counselor/Social Worker Name

Counselor/Social Worker Email

Teacher Name

Teacher Email

To add another child, click the "Add Another Child" button below ↓

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01. Family Interest

02. School/Agency Contact

03. Family Info

04. Referral

School/Agency Referral Form

Family Nav

Reason for Referral

Are any of these factors concerns you have about the family?

No, this is not a concern

Not sure

Yes, this is a concern

School Related Needs

Basic Needs

Family Engagement

What Basic Needs Concerns does the family have (from your knowledge)?

Select allClear choices

Housing

Clothing

Mental Health

Domestic Violence

Chemical Dependency

Medical and or Dental Needs

Childcare

Extracurricular Activities (afterschool programs, Summer Camps, Sports, Etc)

Other:

What type of Family Engagement does the family hope to build (from your knowledge)?

Select allClear choices

Parenting Programs (Parent Power Hour, Parenting Classes)

Family Events (Edible Education, Harvest Fest, Winter Holiday Event, End of School Bash)

Building their Community

Other:

What other community programs is the family working with?

Briefly describe why the family is being referred to the Family Navigation program at EnCompass:

Briefly describe school staff's interactions with the family and what attempts have been made to engage the family in addressing concerns?

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