Referral Checklist

Changing Hearts and Bringing Hope

Lifeline Referral Information Checklist

We need the following details from you to ensure we provide the best service possible for your referral.

Can you please provide us with additional information?

  • Client contact information (name, addresses, phone numbers) for all clients participating in services 
  • Referral Source contact information. Updated FCM contact information and Supervisor information 
  • The reason for the referral (Domestic Violence, Substance Abuse, Medical Neglect, Physical Abuse, etc.) Detailed information will help Lifeline correctly assign the referral in a timely manner. 
  • Any pertinent information (no contact orders, safety concerns, specific medical needs, any known allergies especially for the children, etc.) 
  • Location of visits (home, community, or office) 
  • How many hours per week of visit time 
  • The type of visits (fully supervised, intermittent/partially supervised). No unsupervised visits – Lifeline will not provide transportation only to visits.
  • Dates when visits can start 
  • Transportation information. Who needs to be transported and who has dependable transportation 
  • The family’s availability. If the family is available during the daytime.  

Do you have a question regarding a Lifeline referral? We’re happy to help. Please email referrals@lifelineyouth.org, and we’ll get back to you as soon as possible.

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