Child First Referral Form (retired form)

All information submitted on this referral form is completely confidential, secure and encrypted. After you submit the referral form, you will be emailed a copy for your records.

Child First helps families with children ages 0-5 who are dealing with behavioral, emotional, or developmental concerns or families facing multiple challenges that present a risk to their child's healthy development. Children must have active Medicaid insurance and reside in Guilford County.

Child First teams have extensive training in working with trauma, abuse or neglect and can support families facing a variety of adverse experiences (such as mental illness, substance use, interpersonal violence, homelessness, incarceration and/or extreme poverty).
Child First delivers services in the home or in the community based on the family's preference.
The treatment is designed to strengthen the caregiver and child relationship and to help caregivers understand their child's behavior so unlike occupational or speech therapy, the parent plays an active role in all treatment sessions.

Use this link to download a Child First Program Brochure.

For specific questions about entrance criteria, please call Anita Faulkner @ 336-899-8800 ext. 022 or email: childfirst@famsolutions.org.

REFERRAL SOURCE INFORMATION

Complete this section so we can contact you after the referral has been made.

Name

Name of Your Agency

Phone

Referral Source Email

Has the Parent or Caregiver been informed of the referral?

How did you hear about our Child First program?

Other agency(s) involved with child and/or family:

CHILD INFORMATION

First Name

Last Name

Child's Home Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Will the home visits take place at the child's address listed above? If NO, then enter the address below.

Yes
No
If special circumstances, please explain.

If no, please enter address of home visits:

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Please explain any special circumstances of home visits:

Birthday

Gender

Male
Female

Please Explain

Please Specify

Is child in a childcare center?

Name of Childcare Center

PARENT/CAREGIVER INFORMATION

How many parent(s) or caregiver(s) are present in the home and/or want to participate in the Child First Program?

One
Two
If more than two, please fill out information below and give additional details.

Parent/Caregiver #1 First Name

Parent/Caregiver #1 Last Name

Parent/Caregiver #1 Phone Number

Parent/Caregiver #1 Email

Parent/Caregiver #2 First and Last Name

Parent/Caregiver #2 Phone Number

Parent/Caregiver #2 Email

Parent/Caregiver #3 First and Last Name

Parent/Caregiver #3 Phone Number

Parent/Caregiver #3 Email

Please explain role of Caregiver #3:

INSURANCE/PAYMENT INFORMATION

Active Medicaid Insurance is a requirement for enrollment in this program. Please note at this time that Family Solutions can only accept referrals for Child First for children that have standard plan Medicaid (Healthy Blue, United, Wellcare, Amerihealth, and Carolina Complete).

Does the child reside in Guilford County? The child must reside in Guilford County. If you have extenuating circumstances regarding this requirement, please email your question/situation to childfirst@famsolutions.org

Type of Insurance

Medicaid
NC Healthchoice

Type of Medicaid

Healthy Blue
United Community Plan
Wellcare
Amerihealth
Sandhills LME
Carolina Complete Health Network

Insurance ID #

MENTAL & PHYSICAL HEALTH INFORMATION

Any medical information staff should know about the client (IE: Allergies, Medical Conditions)?

REASON FOR REFERRAL: Briefly describe the reason the child is in need of services.

DESIRED TREATMENT OUTCOMES: Describe the results you hope to see from receiving CHILD FIRST services.

Any additional information you'd like to provide us (history with family, siblings, etc.) or requests you'd like to make (clinician preferences)?

Use this to upload additional documentation you want to send with referral.

Browse (no files uploaded)

PLEASE NOTE: After you hit submit below, a copy of the form will be emailed to you for your records.

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Child First Referral Form (retired form)

Thank you for sending us a Child First referral!