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FAST Referral Form - English

  1. F.A.S.T. Referral Form (2020)

    House Bill 1451 - Family Advocacy Support Team Referral Form
    Serving ages 0-21 with complex needs.

  2. Family Advocacy Support Team
  3. Referral Source
  4. Outside Referral: Family Informed of Referral?*
    Has the person/agency contacted the family, introduced F.A.S.T., and informed them of the referral?
  5. Child Information
  6. Enter in the child's Ethnicity. Examples: African American, Asian, Caucasian, Cora, Hispanic, Native American, Other. You can also enter a mixed ethnicity if applicable.
  7. Special Education?*
  8. Enter the name of the School/Organization the Child is attending if you selected "Other" under "
    "School Attending"

  9. Parent / Guardian Information
  10. Would you like to list other Parent(s) or Guardian(s)*
  11. On each line enter in each additional Parent/Guardian contact. Include the following information:
    Full Name - Relation to Child - Full Address - Contact #
  12. Household Information
  13. Do other Siblings / Children Live in the Household?*
  14. Current Reason(s) for Referral
  15. Fill in any information regarding why you are making this referral. Include anything that applies to School, Placement, Legal Issues, Drugs and/or Alcohol, Home Issues, Safety, Mental Health, Diagnosis, or other extenuating circumstances.
  16. Additional Information
  17. Current Agencies Involved
    Select all agencies the child and/or family is already involved with and provide the contact name for each agency you select below
  18. If you have any questions or concerns regarding information being requested on this form, or feel you need additional assistance, please call the Gunnison County Juvenile Services/F.A.S.T Coordinator at (970) 641-7665, or email them at
  19. Leave This Blank:

  20. This field is not part of the form submission.