Parents As Teachers (PAT) Fill this application out to be considered for the PAT Program. 12135 SE Lincoln St, Portland, Oregon 97216 Referral Request: [email protected] Phone: 503 766 9267 Referral Source* Oregon Department of Human Services (ODHS)WIC OfficeHealth ClinicSelf-SufficiencyPublic SchoolOther ODHS Staff Only Caseworker and Branch Information Name Phone Number Email Supervisor Name Phone Number Email Branch Name Address Identified Safety Threat: 1. No adult in the home is performing parental duties and responsibilities to assure the child’s safety.2. The caregiver’s emotional stability, mental health condition, substance use, or cognitive functioning seriously impairs their ability to supervise, protect, or care for the child.3. One or both parents’ or caregivers’ behavior is impulsive or they will not/cannot control their behavior.4. The caregiver has caused serious physical harm to the child or made a plausible threat of serious physical harm.5. The caregiver has sexually abused the child or there is a plausible threat of sexual abuse.6. The caregiver does not provide supervision necessary to protect the child from potentially serious harm.7. The physical living conditions are hazardous and immediately threatening to the child’s safety.8. A situation, attitudes, and/or behaviors are such that one or both parents or caregivers lack parenting knowledge, skills, and motivation necessary to assure a child’s safety.9. The caregiver is unable or unwilling to meet the child’s immediate and serious medical or mental health needs.10. The caregiver’s actions or inactions result in the child being exposed to violence or serious domestic conflict that threatens the child’s safety.11. The caregiver is unwilling or unable to protect the child from serious harm posed by others.12. The child is fearful of the home situation or people within the home due to threats, intimidation, or past serious harm.13. The child’s own behavior is so out of control that caregivers cannot manage it and the child is at immediate risk of serious harm. Agency Information (Fill out this Section for Non DHS Client Only) Heath Clinic Name Public School Name WIC Office Name Self Sufficiency Name Other Agency Name Referrer Role Name Phone Number* Email Address Participant Section Participant Information Please Provide information for all Participants included in this referral Case Number: How Many Participants?* 1 Participant2 Participants3 Participants4 Participants5 Participants6 Participants7 Participants8 Participants9 Participants10 Participants11 Participants Background Information/ Summary of the issue: Reason for this Referral Referring Agency Desired Goals and Outcomes Additional Information (if any) Participant 1 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 2 Date of Birth -Month -DayYear Participant is: AdultChild Full Name What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 3 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Address Relationship to the case (if applicable) Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 4 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 5 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 6 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 7 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 8 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 9 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 10 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Participant 11 Participant is: AdultChild Full Name Date of Birth -Month -DayYear What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Phone Number Email Primary Language Secondary Language (if applicable) Placement (if Child) Parents/ Legal Guadian's homeSubstitute PlacementProctor Home/ I/DD foster home/ Shelter/ Treatment CenterTemporary Lodging Custody (if Child) Parents/ Legal GuardianODHS Notes (optional): Submit Branch Should be Empty: