BRANCHING OUT HOME

ROOTS THERAPEUTIC ACCESS PROGRAM
Choose one of the following options.
*Partially supervised visits involve a facilitator beginning and ending a visit and periodically checking in on the family.
 Fully Supervised Access Program 
 Partially Supervised Access Program 
REFERRAL SOURCE: *
Agency Name (if applicable)
Name * Individual completing the referral form.

Prefix 		 
First 		 
Last 		 
Suffix
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
PHONE NUMBER: *

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CELL PHONE NUMBER:

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EMAIL: *
Confirm EMAIL *

FAMILY DETAILS:
Please complete the information on each of the parents beginning with the Custodial Parent.
Name Custodial Parent Information.

First 		 
Last
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Phone Number *

### 		-
### 		-
####
Cell Phone Number

### 		-
### 		-
####
Name Non-Custodial Parent Information

First 		 
Last
Address *

Street Address

Address Line 2

City
State / Province / Region

Postal / Zip Code
Country
Phone Number *

### 		-
### 		-
####
Cell Phone Number

### 		-
### 		-
####

CHILDREN:

Please include the Name and Date of Birth for all participating children.
Name *

First 		 
Last
DATE OF BIRTH: *

MM 		/
DD 		/
YYYY
Name

First 		 
Last
DATE OF BIRTH:

MM 		/
DD 		/
YYYY
Name

First 		 
Last
DATE OF BIRTH:

MM 		/
DD 		/
YYYY


Please continue down to the Summary - Request for Services portion, if this is a private referral.

SUMMARY - REQUEST FOR SERVICES

Please complete section below including any information you feel may assist us in processing you application and matching your needs to the expertise of our facilitators and therapists.
SUMMARY OF INFORMATION: * Please write a brief description as to the nature of the request, in order to assist in processing request by matching the needs of the applicant with a suited facilitator / therapist.
Upload Case File or Relevant Documentation:
Forward documentation you feel may be relevant in assisting facilitators meet the needs of the family.
BILLING OPTIONS: *
 Bill Legal Counsel Directly 
 Bill Custodial Parent Directly 
 Bill Named Agency 
 Retainer 
BILLING DETAILS / INSTRUCTIONS:
AUTHORIZATION:
By electronically submitting this application you are authorizing and agreeing to the terms outlined in the applicaiton. *
 As an Authorized Individual, I agree to the terms outlined. 
 As Custodial Parent I agree to the terms outlined. 
My child will be supervised during all activities.
Sessions will be taped for the purpose of supervision and training only.
I give permission for Branching Out staff to administer emergency medical treatment or involve professional medical staff if necessary.
I understand that if I do not attend a session without 24 hours notice, I will be charged for the entire session.
I understand should the decision be made to end sessions, I will agree to (2) additional closure session in the best interest of the children.
I understand and agree that the purpose of the Roots Therapeutic Access program is not designed or intended to determine custody arrangements or parental suitability.
Authorizing Signature:
Date:
Authorizing Signature:
Date:
This section will be signed by both parents upon commencing program, for Branching Out files.
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