Referral Form

Referral Contact Information
Your Name*
Your Email*
Child Information
Name of Child*
Age of Child*
Our focus is primarily 5-13 year olds, but we are flexible.
Identified Gender
Total number in household
Please provide siblings and ages.
Please introduce us to the child/children being referred (current situation, likes/dislikes, and any special needs).
Does the child like stuffed animals?
- Yes
- No
Child's Address
Street Address City State ZIP Code
Parent Information
Parental Status
- Separated
- Divorced
Approximate date of separation or divorce
Church Information
Name of Church Attended
Name of Church Pastor
Care Package Questions
Flashlight Color Preference
- Black
- Blue
- Either color
Preferred dining establishment for a family meal
- Old Spaghetti Factory
- Olive Garden
- McDonald’s
Would the child enjoy attending a Portland Trail Blazer basketball game or Timbers soccer game?
*seasonal and subject to availability
- Yes
- No
Do you like watching movies with your family in the theater?
- Yes
- No
If the above answer was yes, which movie theater do you prefer?
- Cinemark
- Regal
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13203 SE 172nd Ave.
Suite 166 #226
Happy Valley, OR 97086
Phone: 503-774-8426

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DIVORCE ADJUSTMENT & RECOVERY FOR KIDS