Fatherhood Program Referral Form

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Greetings, and thank you for the referral. To refer a potential father, please complete this form in as much detail as possible and click the submit button. For general questions, please contact A Father's Place, Prince George's County, at ccdss@afppgc.org or 240-391-8892.

Email *

REFERRAL CRITERIA

Before entering potential participant data, please check all boxes to confirm that the potential participant meets the Charles County Department of Social Services criteria for receiving A Father’s Place, Prince George’s County support. If you are unsure or want to discuss a possible referral, do not hesitate to contact ccdss@afppgc.org or call 240-391-8892.

The Father or Male Role Model Resides in Charles County, Maryland. This fatherhood program will explicitly serve fathers in Charles County, Maryland. Fathers are also eligible if they do not live in Charles County but have an active child support case in Charles County. Fathers may be expectant fathers, single fathers, married fathers, returning citizens, foster/adoptive, and male role models, such as grandfathers, uncles, and guardians who need assistance developing a caring relationship with their children.

The Father or Male Role Model is 18 years of Age or Older. This program can only support adult fathers who are 18 or older. We are happy to direct younger fathers to resources that may help them during their pre-adult years.

The Father or Male Role Model Has at Least One Child 18 or Younger. We are focusing on programming for fathers with children 18 or younger. We want to ensure we impact those families with children at earlier generations to help set the stage for further growth and development.

The Father or Male Role Model is Commitment to Becoming the Best Father They Aspire To Be. We sincerely appreciate the commitment of every father or male role model to becoming the best father they aspire to be. A decision to join our fatherhood program is a powerful step for a dad toward strengthening their bond with their children and enhancing their skills as a dad.

The Father or Male Role Model Can Consistently Commit to Engaging With A Father’s Place, Prince George’s County.

Required

REFERRAL SOURCE TYPE

Please check the appropriate box. *

Adoption

Adult Services

Child Protective Services

Child Support

Court or Court-Appointed Program

Employment Services

Faith-Based Organization

Food Stamps (SNAP)

Foster Care

Healthcare Organization

Hotline

The Jude House, Inc.

Kinship Care

Local Community

Postcard Flyer

Public Assistance to Entrepreneurship Program (PA2E)

Resources Unit

Schools, Colleges/Universities

Social Media

Temporary Cash Assistance (TCA)

Website

Other:

Required

Option 1

Clear selection

REFERRAL SOURCE

Name of Person Making the Referral (First Name, Last Name) *

Referral Agency or Organization *

Referral Contact Number (123-123-1234) *

Referral Email Address *

County of Referral Source *

POTENTIAL PARTICIPANT

Father's Name (First, Middle, Last) *

Father's Home Address (Address, City, State, ZIP Code) *

Father's Home Number (123-123-1234)

Father's Cell Number (123-123-1234)

Father's Email Address

Date of Birth *

YYYY

Education Level *

Citizenship Status *

What is the Father's Primary Language?
*

Is the Father Employed? *

Yes

Did the Father Serve, or Are They in the U.S. Military?
*

Yes

Marital Status *

Total Number of Children *

Does the Father Have an Active Open Child Support Case with the Charles County Office of Child Support?
*

Yes

SUPPORT NEEDS & RISKS / NOTES

Please use this space to tell us about any support needs, risks, or other relevant information you or the potential participant would like us to know.

CONSENT / RELEASE OF CONTACT INFORMATION

Please confirm that the potential participant has authorized you to submit this referral on their behalf and that they are happy to be contacted by A Father's Place, Prince George's County (AFPPGC). Once the referral is received, we will ask the participant to consent to the AFPPGC Voluntary Informed Consent and Confidentiality Agreement before proceeding.

Yes

Required

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