Our goal at Children’s Homes is to be able to serve a child or a sibling group that is in need of out-of-home residential care. Our services are comprehensive in order to serve today’s troubled youth. Please complete this form to help us better understand the problems of the child or children that may need our help. We will review the information and get back to you as soon as possible. NOTE: This is not an Admission Form; it is a Referral. If we feel your child will benefit from our program, we will provide an admission form for you.

Click this button to begin the referral process:

Select (by clicking) the applicable answer/answers. Some entries will allow you to make multiple selections; others will require you to select only one option. Please be sure to make your selection(s) and double-check them before hitting the Submit or Next button.

Presenting Problems for the Child (select ALL that apply):

Do you have medical insurance?

School Problems for the Child (select ALL that apply):

Behavioral Problems for the Child (select ALL that apply):

Child's Last Name:

Child's First Name:

Child's Date of Birth:

Child's Race/Ethnicity:

Child's Gender:

Legal Guardian:

Child is Living With:

Child's School:

Child's Grade:

Please tell us how you learned about Children's Homes:

Your Last Name:

Your First Name:

Your E-mail:

Your Address:

Your City:

Your State:

Your ZIP Code:

Your Home Phone:

Your Work Phone:

Please include any other pertinent comments:

Your Fax Number: