Referral form for DADS Program
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  • Interest form for the DADS Program

  • Thank you for your interest in DePelchin Children's Center Fatherhood Programs. Please complete this form if you are interested in participating in our programs or to refer any fathers, father figures and/or co-parents.

     

    If you need to speak with a DePelchin Representative for guidance, please call (713)730-2335. 

  • How did you hear about us?*
  • How can we help you?*
  • Format: (000) 000-0000.

  • Referral

  • Today's Date
     / /
  • Who is this referral for?

  • Provider Information

    If this is a self-referral, please enter N/A when appropriate.
  • Format: (000) 000-0000.
  • Did the caregiver provide verbal consent for DePelchin Children's Center to receive referral information?*

  • Parent Information

    Please provide the following information on the Parent or Caregiver being referred. If this is a self-referral, please add your contact information on this section.
  • Parent's Date of Birth:
     / /
  • Race

  • Co-parent Information (If applicable)

    Please provide the following information on the co-parent (spouse, partner, etc.)

  • Additional Referral Information on the Parent

    This information will help us identify program eligibility for prospective clients. If this is a self-referral, please answer these questions about yourself.
  • Did the parent provide consent for DePelchin Children's Center to receive referral information?*
  • Does the parent have a child/youth ages 24 years or younger?*
  • Is the parent co-parenting the child/youth identified above?
  • Is the parent expecting a baby?
  • Parent Concerns (select all that apply):
  • 0/320

  • Availability

  • Please provide your prefered availability? (This is not guaranteed)

  • Thank you for your submission!

    You will hear from us soon!
  • Should be Empty: