Parents As Teachers (PAT) Referral Request: [email protected] | Phone: 503 766 9267 Referral Referral Source* Please Select Oregon Department of Human Services (ODHS) WIC Office Health Clinic Self-Sufficiency Public School Other Full Name First NameLast Name Date of Birth -Month -DayYearDate What is your gender: Please Select Male Female N/A Ethnicity Participant Number: Relationship to the case (if applicable) Address Street Address Street Address Line 2CityState / ProvincePostal / Zip Code Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Phone Number Please enter a valid phone number.Format: (000) 000-0000. Email [email protected] 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) ODHS Staff Only Caseworker and Branch Information Name Phone Number Format: (000) 000-0000. Email Supervisor Name Phone Number Format: (000) 000-0000. 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* Format: (000) 000-0000. Email Address Participant Section Participant Information Please Provide information for all Participants included in this referral How Many Participants?* Please Select 1 Participant 2 Participants 3 Participants 4 Participants 5 Participants 6 Participants 7 Participants 8 Participants 9 Participants 10 Participants 11 Participants Other Case Number: 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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 Format: (000) 000-0000. 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): Branch Submit Should be Empty: