Starfish Referrals

Let’s talk 👋 Complete the referral form below and one of our Parent Educators will get in touch with you as soon as possible!

Get in Touch

223 Broad St NW

Cleveland, TN 37311

USA

familycornerstonesstarfish@gmail.com

Call or Text Us (423) 464-6583

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Submit an Online Referral

Referral Agency (If Self-Referral, submit “SELF”)(required)

Person making referral(required)

Email(required)

Phone(required)

Parent Name(required)

Parent Address: (Street, City, Zip Code)(required)

Parent Telephone(required)

Primary Language in Home: Select ONE(required) English Spanish

Select one(required) Expecting Parent? Yes No

1. Child’s Name(required)

1. Child Birth Date (Due Date if mother is expecting)(required)

2. Child’s Name

2. Child Birth Date (Due Date if mother is expecting)

3. Child’s Name

3. Child Birth Date (Due Date if mother is expecting)

Check ALL that apply. (At least one family characteristic must be met for family to receive our free in-home visits.)(required) Teen Parent: Parent is under the age of 20 during the program year.

Child with Disabilities or Chronic Health Conditions: Child being served has a physical/cognitive/emotional/or health-related condition or impairment that substantially limits one or more major life activities or qualifies the child for services under IDEA Part C.

Parent with Disabilities or Chronic Health Conditions: Parent has a physical/cognitive/or other health-related condition or impairment that substantially limits one or more major life activities.

Parent with Mental Illness: Parent has been diagnosed with a thought/mood/or behavior disorder or some combination of disorders associated with distress and/or impaired functioning.

Low Educational Attainment: Parent did not complete high school or GED and is not currently enrolled.

Low Income: Family is eligible for free and reduced lunches/public housing/child care subsidy/WIC/food stamps/TANF/Head Start/Early Head Start/and or Medicaid.

Recent Immigrant or Refugee Family: One or both parents are foreign-born and entered the country within the past five years.

Substance Abuse: Parent has used or is currently using substances despite negative social/interpersonal/legal/medical/or other consequences.

Court-Appointed Legal Guardian(s) and/or Foster Care: Child has court-appointed legal guardian(s) or is in foster care.

Homeless or Unstable Housing: The family lives in emergency/transitional housing or in a place not intended for regular housing and/or moved more than twice in the past year due to problems with housing.

Incarcerated Parent(s): Parent is incarcerated in federal or state prison or local jail or was released from incarceration within the past year.

Very Low Birth Weight: Birth weight is under 1500 grams or 3.3 pounds.

Death in the Immediate Family: Child/parent/or sibling as died.

Domestic Violence: Parent is involved in intimate partner violence.

Child Abuse or Neglect: Abuse or neglect of child or sibling is suspected or substantiated

Military Family: Parent/Guardian is currently deployed or is within two years of returning from a deployment as an active duty member of the armed forces.

Ongoing Health Problem of the Child/Parent/Sibling: Ongoing health problem is serious enough to substantially limit one or more major life activities.

Other: Explain Below in Special Concerns

Special concerns of parent or agency?

Submit