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Committed to fostering self-reliance and community engagement.
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Home
About
About KRFDC
Community Action
Board of Directors
Leadership
Get Involved
Programs
Community Services
About Our Services
Energy Assistance
kynect
Tax Prep Services
Opioid Response
Healthy Marriage & Relationships
Responsible Fatherhood
Community Collaboration for Children
Eastern Scholar House Program
About Us
Tour
Workforce Pathway at Kit Carson Commons
About Us
Tour
Liberty Place
Health & Wellness Center
About Our Clinic
Patient Information
Our Team
Affordable Housing
Weatherization
Supportive Services for Veteran Families
Aging Services
Foothills Active Day Center
About Us
Transportation
About Us
Services & Bus Schedules
News
Foothills News
Jobs
Contact Us
CCC In-Home Services Referral Form
Step
1
of
3
33%
Referral Information
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
Email
Family Information
List all adults in the home:
Name
Sex
Date of Birth
Race
Relationship to Child
Add
Remove
List all children in the home:
Name
Sex
Date of Birth
Race
Add
Remove
Are your children currently living in the home?
Yes
No
Is there any pending court action?
Yes
No
If YES is selected, please list the next court date
Services needed:
Describe your family strengths, resources and progress made:
List below other agencies that are involved with your family:
Please check below your assessment of potential for physical violence:
Within the Family
Extreme
High
Moderate
Low
None
Towards Others
Extreme
High
Moderate
Low
None
Do you have custody of the children?
Yes
No
Is your family currently involved in DCBS?
Yes
No
ALL INFORMATION MUST BE COMPLETED! THANK YOU!
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