Referral for Art of Parenting Group

Childrens Home Association of Illinois

Date: _
Client/Parent Information
Client/Parent Name: _____________________________________________________
Address: ______________________________________________________________
Phone Number: _________________________________________________________
Ages of children (if known): _________________________________________________
Reason for Referral: ______________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Referral Source
Name/Position: ________________________________________________________
Agency or Organization: _________________________________________________
Email and Phone Number: ___________________________________________________________
Have your informed your client of this referral? _________
Is this court ordered? _________
How often would you like a report? There is a mandatory one at the end of the 6 weeks, but would
you like it more often? If so, please indicate when you would like reports and in what format (email or
phone call)? _____________________________________________________________________
________________________________________________________________________________
Childrens Home Association of Illinois
Attn: Melissa Sallee
2130 N. Knoxville Ave
Peoria, IL 61603
Questions? Call Mel at 309-687-7321
Fax 309-687-7421 msallee@chail.org