ROOTS Ohio – Interest & Referral Form – ROOTS Ohio | Support for Pregnancy, Parenting & Family Care

1 Contact Information

1. Full Name

Prefer not to disclose my name

2. Preferred Name (if different)

3. Date of Birth

Prefer not to disclose my day of birth

4. Phone Number (Required)

5. Email Address

6. Preffered Method of Contact

7. Best Time to Contact You

2 Location & Demographics

8. City & County of Residence

9. Zip Code

10. Are you currently pregnant or parenting an infant (birth–12 months)?

11. How far along are you in your pregnancy (if applicable)?

3 How Did You Hear About Roots Ohio?

If “Other,” please specify (optional):

13. If referred by an organization or individual, please list their name (if known):

4 Services Of Interest

14. What types of support are you interested in receiving? (Check all that apply)

Parenting education and support Pregnancy support and education Emotional wellness / mental health support Family or relationship support Case management / care coordination Referrals to community resources Support related to adoption or parenting decisions Support navigating systems (healthcare, child welfare, courts, etc.)

5 Program Partner Connection

15. Are you interested in being connected to services from one or more of the following ROOTS OHIO partners?
(Selecting an option allows information sharing for referral purposes only.)

Hope, Love, and Dream, Inc. – trauma-informed mental health, family, and parenting support Adoption Circle – adoption education, counseling, and decision-support services POEM of MHA – pregnancy, maternal mental health, and peer-based supports I’m not sure — please help determine the best fit

6 Current Needs & Concerns

16. What are your primary concerns or goals right now? (Open-ended response)

7 Safety & Urgency (Screening Only)

17. Are you currently experiencing any urgent safety concerns?

No Yes — I would like help connecting to immediate support Prefer not to say

If you are in immediate danger, please call 911 or your local emergency number.

8 Consent & Acknowledgments

18. Consent to Contact

I give permission for ROOTS OHIO program staff to contact me regarding services and supports.

19. Consent to Share Information for Referral Purposes

I consent to limited information sharing between ROOTS OHIO partner organizations (HLD, Inc., Adoption Circle, and POEM of MHA) for the purpose of referral and care coordination.

20. Acknowledgment

I understand this form is for screening and referral purposes only and does not guarantee services.

Signature (Type your full name)

ROOTS OHIO Parenting & Pregnancy Program

Interest & Referral Form