Self-Referral Form

WE CAN HELP YOU

Filling out the form below allows us to provide your family with the best possible service.

If you need assistance completing this form, call us at (541) 779-5242.
Or email us at info@familynurturingcenter.org

Your Name *(required)
Today's Date *(required)
Phone Number *(required)
Email *(required)
Preferred Language *
Address
(required)Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Preferred FNC Location *
Do you have children under age 6? *

Child's Full Name
Child's DOB
Child's Full Name
Child's DOB
Child's Full Name
Child's DOB
Child's Full Name
Child's DOB
Please let us know which of these FNC services you would like to know more about *
How would you like FNC to contact you to share more information about services? *

Don't hesitate to get in touch! info@familynurturingcenter.org or (541) 779-5242

Confidentiality: We appreciate your letting us get to know you and your family, and we will maintain your privacy. Relevant family information is thoughtfully and respectfully shared between programs and appropriate staff members here at the Family Nurturing Center. This sharing of information allows us to provide your family with the best possible service. What we talk about is private, but there is an important exception. All of the people who work for the Family Nurturing Center are mandated reporters of child abuse. This means that we are required by law to let DHS or a law enforcement agency know if we have any reasonable cause to believe a child is unsafe or has been harmed. If we are ever required to make a report, we will support your family through the process in whatever way possible, and will continue to provide services to you and your family. We know that parenting is hard work, and we will partner with you to keep your family safe. The staff at the Family Nurturing Center will do all that we can to support parents and families. Please talk to your child’s teacher/care coordinator if you have questions.