Fillable REFERRAL FOR SERVICES (Merced County Office of Education)

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REFERRAL FOR SERVICES (Merced County Office of Education)

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Rev. 9/15/20 FSS-F19
REFERRAL FOR SERVICES
To Participating Agencies:
Please use this form for any child that you are referring to Head Start/Early Head Start. Fax the completed form,
with a fax cover page to (209) 381-5172 or email to HeadStartRef@mcoe.org. Staff will be contacting the family,
using the information you provide below, within the next two weeks. If you have any questions as to the status of
this referral, please contact the Family Support Services Manager at (209) 381-5170.
Date of Referral: ____________ Referring Agency: _______________________________
Agency Contact: ______________________ Contact Phone: _______________________
Contact Email: _____________________________________________________________
Child’s Name: ____________________________________ Date of Birth: ______________
Parent/Guardian Name: ____________________________ Relationship: _______________
Parent/Guardian Name: ____________________________ Relationship: _______________
Family Address (street #, street name, City): _____________________________________________
Phone Number: ______________________ Alternate Phone: ________________________
Primary language ___________________________
Is the parent/guardian aware they have been referred to Head Start?
Do the parent(s)/guardian(s) work full-time, in a training program or on medical respite?
Reason the child/family is being referred: ________________________________________
________________________________________________________________________
Atwater
Delhi
El Nido
Gustine
Hilmar
LeGrand
Livingston
Los Banos
Merced
Planada
Santa Nella
For office use only
Assigned to: ____________________________
Date Assigned: __________________________
Dates contacts were conducted:
Contact 1: ______________________________
Contact 2: ______________________________
Contact 3: ______________________________
Status of Application:
Complete
Incomplete
Not Interested
Date referring party was notified ___________
Send c
ompleted referral form to the secretary
Family Information
Agency Information
Circle Program Options of Interest
Legend
• EHS: Pregnant Woman and infants 0 to 3 years old
• HS: children 3 to 5 years old
South Dos Palos
Stevinson
No
No
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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REFERRAL FOR SERVICES (Merced County Office of Education)

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Completed 11 May 2021

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