CFS Service Referral (Self or Agency)

CITC Family Wellness Referral - Agency or Self
ParticipantId
If you have any questions or need help filling out this referral, please call the Family Wellness front desk at 907-793-3132 or email FWDept@citci.org. Thank you.
Which of these best describes your situation:*

I'm providing a professional referral on behalf of a participantI'm requesting CITC's Child and Family program services for myself
OCS/Non-OCS

OCSNon-OCS

Referral Information
Referring Agency (Please enter Cook Inlet Tribal Council, if the referral is being provided by another CFS or other CITC program.)*
If referred by CITC, please list the department or subsidiary
Staff First Name*
Staff Last Name*
Staff Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Staff Email*
example@example.com
Reason for Referral*
Referral Notes: Is there anything else you would like us to know about this referral?
Please attach a copy of your agency's Release of Information form.

Cancelof

Primary Parent Contact Information
Physical Address*
Physical Address (Deprecated Kept for Data)

Street Address

Street Address Line 2

CityState

Zip Code
Is your mailing address the same as your physical address?*

YesNo
Mailing Address*
Mailing Address (Deprecated Kept for Data)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
If this participant does not have an email address, please type 'Unknown' here and leave the email address blank.
Primary Phone Number*
Enter all '5's if no number exists.Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best method of contact*

Primary phoneSecondary phonePersonal email
Is it safe for CITC to contact you at your preferred phone number?*

YesNo
What is the best time to contact you?*
Is there any additional information that will help us in contacting you?
Is there a secondary parent who will also be involved in program services?*

YesNo

Children's Information
Is your child(ren) currently involved in any other early childhood services?*
Please provide information for all children living in the home and outside of the home. For prenatal, write "prenatal" in First Name, your last name in Last Name, and due date in Date of Birth.
Child Information*
Submission Time

Hour Minutes
Should be Empty:

CITC Family Wellness Referral - Agency or Self