PeerPlace Public OH-Cuyahoga-FCFC Portal

REQUEST FOR SERVICES

Please complete as much information as possible so we can make the best possible referrals for you.

Required Fields (marked with an * asterisk) must be completed.

Requester Information

Requester Name *:

Requester Phone (###-###-####) *:

Requester Phone (###-###-####) * - -

Requester Agency Name (if applicable):

Requester Phone Ext.:

Requester Email Address:

Information on Person Needing Services

First Name of person needing services *:

Last Name of person needing services *:

Gender:

Date of Birth (mm/dd/yyyy) *:

Who told you about the program?:

If Other, please specify:

Is the child / youth currently involved with a service provider?:

Name of Agency and / or Private Provider:

Issues / Needs:

Issues / Needs: Select One or More

I need information

I am looking for a service

I need Service Coordination

I want to apply for Multi-system Youth

Other (specify below)

If other, please explain in Comments box below

Comments - Please provide any addiitonal information related to services needed:

Child / Youth School District:

School (other):

Is youth currently in the hospital or crisis bed:

If yes, where is youth currently in the hospital or crisis bed:

Contact Information for Person Needing Services (i.e. provide Parent / Guardian information for Minor Children)

Parent / Guardian First Name *:

Parent / Guardian Last Name *:

Parent / Guardian Date of Birth (mm/dd/yyyy):

Parent / Guardian Relationship to Child / Youth:

Address 1:

Address 2:

City:

State:

Zip Code:

Homeless:

County:

The family must live in Cuyahoga County

Phone (Home) (###-###-####):

Phone (Home) (###-###-####) - -

Phone (Cell) (###-###-####) *:

Phone (Cell) (###-###-####) * - -

Phone (Work) (###-###-####):

Phone (Work) (###-###-####) - -

Email Address:

Preferred Method of Contact:

Best Time to Contact:

Are there other minors in the home:

Name of sibling / relative child

Sibling / Relative First Name:

Sibling / Relative Last Name:

Date of Birth (mm/dd/yyyy):

Sibling / Relative First Name:

Sibling / Relative Last Name:

Date of Birth (mm/dd/yyyy):

Sibling / Relative First Name:

Sibling / Relative Last Name:

Date of Birth (mm/dd/yyyy):

Sibling / Relative First Name:

Sibling / Relative Last Name:

Date of Birth (mm/dd/yyyy):

Consents

I attest that I have obtained consent from the client to share client profile information with the agency(ies) selected. *:

I attest that consent has been given to disclose general medical information *:

Process Request: