Referral Forms

The Social Empowerment Center offers DFCS contracted services such as In-Home Therapy, Early Intervention, Parent Aide and Wraparound services.  We also conduct Comprehensive Child and Family Assessments (CCFA’s) and offer counseling and therapy funded by private insurance and Medicaid (including Intensive Family Intervention).   The referral forms for these services are listed below.

Download the form.  Print form and fax to:  1-866-468-1886
or email the completed form to: