Updated 7/18/17
A program of the El Paso County Department of Human Services
325 North El Paso, Colorado Springs, CO 80903 • (719) 634-7797
Fathering is for Life. Date of Referral:
Community Based Referral Form
Please email to
DHSCenteronFathering@elpasoco.com
Name of Individual/Agency Making Referral: Phone #:
Name of Father: Phone #:
Address of Father:
Is father aware that this referral is being made? Yes No
Reason for individual/agency involvement:
Current status of father’s involvement with family:
List any restrictions on father-child contact:
List which service you are referring father to (please include court-orders, as applicable):
Supportive Services, i.e. Weekly Support Group or mentoring
Parent Education, i.e. 15-week Fathering Class: (Includes topics related to child development, discipline, co-parenting,
communication, play, building relationships, self esteem)
10-week ‘Conflict Resolution for Dads’ class: (Includes topics on traditional approaches to conflict compared to
innovative approaches, conflict and gender, influence of emotions on conflict, how conflicts with others influence conflicts
with one’s children)
8-week ‘Fathers as Providers’: Designed for fathers who are unemployed or underemployed – TANF or TANF-eligible -
includes topics on enhancing interview skills, completing job applications, updating resumes and assistance in making
contacts with area employers)
13-week ‘Nurturing Fathers Program’: (Includes topics on nurturing ourselves and our children, discipline without
violence, dealing with feelings, managing anger and resolving conflict, balancing work and fathering and cultural
influences)
Other Services Not Listed Above (please specify): ______________________________________________________
________________________________________________________________________________________________
Do Not Write Below This Line
Date(s) Contact Made: _____________________________________________________________________
Outcome of Contact:
________________________________________________________________________________________
Email:
