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

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

3. 
5. Referral Source
7. Name*
8. Organization (if applicable)
10. Contact Number*
11. Fax Number (if applicable)
12. Contact Email
14. Referral Made By*
    -- Select One --Self ReferralOutside Referral
15. Outside Referral: Family Informed of Referral?*

    Has the person/agency contacted the family, introduced F.A.S.T., and informed them of the referral?

    1. Yes

    1. No
19. Child Information
21. Childs Legal Name*
22. Date of Birth*
    Date of Birth
23. Age*
    -- Select One --0-123456789101112131415161718192021
25. Gender*
26. Ethnicity*
    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.
27. Primary Language*
29. Insurance Information
    -- Select One --HMO/PPO/OtherMedicaidUninsured
30. Insurance (Other)
32. School Attending*
    -- Select One --Crested Butte Community SchoolGunnison ElementaryGunnison Middle SchoolGunnison High SchoolLake City Community SchoolLake Preschool & KindergartenMarble Charter SchoolOnline / Home SchooledOther
33. Grade*
    -- Select One --Preschool/Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeOther
34. Special Education?*

    1. Yes
    2. No
36. School Attending (If "Other" selected)

    Enter the name of the School/Organization the Child is attending if you selected "Other" under "
    "School Attending"

40. Parent / Guardian Information
42. Parent / Guardian Name*
43. Contact Number*
44. Contact Email
46. Home Address*
47. Relation to Child*
    -- Select One --ParentRelativeFoster ParentLegal GuardianOther
49. Would you like to list other Parent(s) or Guardian(s)*

    1. No

    1. Yes
50. Additional Parent(s) or Guardian(s) - How Many?
    -- Select One --123 or more
52. First Parent/Guardian Name
53. Relation to Child
55. First Parent/Guardian Address
56. Contact #
58. Second Parent/Guardian Name
59. Realtion to Child
61. Second Parent/Guardian Adress
62. Contact #
64. Additional Parent/Guardian listing
    On each line enter in each additional Parent/Guardian contact. Include the following information:
    Full Name - Relation to Child - Full Address - Contact #
68. Household Information
70. Do other Siblings / Children Live in the Household?*

    1. Yes

    1. No
71. If Additional Siblings / Children, How Many?
    -- Select One --123 or more
73. 1. Sibling / Child Name
74. Date of Birth
    Date of Birth
75. Gender
77. 2. Sibling / Child Name
78. Date of Birth
    Date of Birth
79. Gender
81. Sibling / Child Information (One Per Line: Child Name / Date of Birth / Gender)
83. Special Accommodations? (if any - e.g. Interpreter, Physical/Sensory Disabilities, Medical Needs, Limitations, Etc)
87. Current Reason(s) for Referral
89. Why Now?*
90. Precipitating Events?*
92. Additional Information / Reason(s)
    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.
96. Additional Information
98. 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

    1. DHS - Child Welfare
    2. DYC (Department of Youth Corrections)
    3. Mental Health Services
    4. Juvenile Diversion
    5. Probation

    1. School Services
    2. Health Services
    3. Gunnison Valley Mentors
    4. Project Hope
    5. DVR (Department of Vocational Rehabilitation)
100. DHS-Child Welfare
101. DYC Contact
102. Mental Health Contact
104. Juvenile Diversion
105. Probation Contact
106. School Contact
108. Health Services Contact
109. GV Mentors Contact
110. Project Hope Contact
112. DVR Contact
114. Additional Information / Strengths / Interests
118. 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 fastcoordinator@gunnisoncounty.org.
Leave This Blank:


120. 1. Receive an email copy of this form.
121. Email address

     This field is not part of the form submission.

122. Submit

* indicates a required field