PAT Referral Form – Columbia County Family Center

Parents Name

Address

Email (if applicable)

Phone

Child(ren)'s Name(s)/ Date of Birth/ Gender

Referring Agency & Staff (if applicable)

When in the best time to contact you?

Do you or your children have Medicaid insurance? If yes, name of provider?

How did you learn about the Family Center?

Parents As Teachers Intensive PAT Program/Weekly Services (OUD/SUD concerns) Please Check Box if Safety Plan is in Place