Compass of Carolina : Appointments & Forms : Referrals : Second Chance

Second Chance

Second Chance Referral Form

If you have any questions about Second Chance, please contact Nicole Sheppard at 864-467-3434, ext. 3328 or sheppardn@compassofcarolina.org.

If you are seeking help for an individual who may benefit from the Second Chance Program, please complete the referral form below. You may send the form electronically or you may download the pdf version and mail it to:

Compass of Carolina
Attn: Nicole Sheppard
1100 Rutherford Road
Greenville, SC 29609

Click Here - To Download Second Chance Referral Form

Second Chance Referral Form-Electronic Form

Referral Agent's Name

Organization

Referral Agent's Address

Referral Agent's Phone

Referral Agent's Email

Who should be contacted with the results of this referral?

Have you informed the family you are making this referral?

If so, what was the family's response?

Identified Child's First Name

Identified Child's Middle Name

Identified Child's Last Name

Identified Child's Date of Birth

Identified Child's School

Does this child live at home?

If not, where and with whom is the child currently living?

Number and Ages of Siblings

Parent or Legal Guardian First Name

Parent or Legal Guardian Middle Name

Parent or Legal Guardian Last Name

Caretaker's Address

Caretaker's Phone

If Other Please Describe Here

What Other Services/Agencies are currently being used or have been used in the past and to address what issue?

Is the Child/Parent currently on medication?

If yes, what are the medications and dosages?

Does the child have any educational, physical or mental health diagnoses?

If yes, please indicate what the diagnosis is

What would you identify as the child's or family's strengths?

Questions

Comments

Preferred Response

Email
Phone
Fax
Mail

Form Completed By

Date