"*" indicates required fields

The Family Resource Center Referral

This form is for providers who are referring clients for PAT home visits, resources/referrals, and developmental screenings (Ages & Stages Questionnaire). For questions about referrals, please call 860-437-4550.
Please complete this form to the best of your knowledge.

Child's Information

Name*
MM slash DD slash YYYY
Address*

Medical & Dental Information

(Check all that apply)
Uninsured?*
Immunized*
Dental Checkup*
Dental Care*
Medical Care*

Race and Ethnicity

(Check all that apply)
Are you Hispanic or Latino?*
Ethnicity*

Parent/Guardian Information

Name*
Address*

Medical & Dental Information

(Check all that apply)
Uninsured*
Immunized*
Dental Checkup*
Dental Care*
Medical Care*
Are you Hispanic or Latino?*
Ethnicity*

Family Assessment, select Yes or No

Chronic health problems, e.g., asthma, obesity*
Chronic school or preschool attendance problems*
Developmental delays*
Disabilites*
Frequently changed schools in short periods of time*
Very Low birth weight*
Low birth weight*
Premature birth*
Reading or other academic challenges*
Serious behavior concerns*
Suspended or expelled from early care or early education*
Serious oral health problems*
Abuse or neglect*
Chronic unemployment or underemployment*
Death of parent or other family member*
Divorce or estrangement of parent*
Domestic violence*
Involved with multiple health / social service agencies*
Foster parents, court-appointed guardians*
Grandparent/other relative is primary caregiver*
High crime neighborhood*
Homeless or numerous family relocations*
Low educational attainment*
Low income*
Immigrant or refugee status*
Multi-sibling family*
Military family*
Parent in active duty*
Parent incarcerated*
Parent with disabilities*
Parent with chronic health problems*
Parent with chemical dependencies*
Single-parent household*
Speakers of other languages (ELL)*
Teen parent(s)*
Parent with mental illness*
Young parents*
Child with disability or chronic condition*
Parent with a disability or chronic condition*
Parent with mental health issue(s)*
High school diploma or equivalency not attained*
Recent immigrant or refugee family*
Substance use disorder*
Foster care or other temporary caregiver*
Child abuse or neglect*
Parent incarcerated*
Housing instability*
Very low birth rate and preterm birth*
Death in the immediate family*
Intimate partner violence*
Military deployment*
MM slash DD slash YYYY