COPES, Inc. - Referral Form.

CREATING LASTING FAMILY CONNECTIONS

COPES, Inc. provides their nationally recognized*, evidence-based curriculum, Creating Lasting Family Connections (CLFC), valued at $750 for participation, at no cost to individuals or married couples in the Louisville Metro area that meet at least one of the following:

* One or both partners have been incarcerated and are now living in the Louisville Metro Area
* One or both partners are in recovery from alcoholism/chemical dependency

To make a referral, please fill out the information below or download a printable version of this form and fax to COPES at 502-583-6832. A COPES’ staff member will contact you within a few days of receiving the fax.
Name:
Address:
City:
State:
Zip:
Home Phone Number:
Cell Phone Number:
Email Address:
How did you hear about our program:
If you heard about us from an Agency:  
Agency Name:
Agency Contact Person & Number:
Do you believe your spouse is willing to participate with you in our Marriage Enhancement Program? Yes    No    Unsure
Will you need financial assistance for childcare during the hours of participation of this program? Yes    No    Unsure
Comments:

     

                                   

 
Printable Form
MS Word version of our referral form
PDF version of our referral form (Please note: The download file is in PDF format. You can get the latest Adobe PDF Reader® directly and at no charge from www.adobe.com.
 
 

*Nationally Recognized by: National Registry of Evidence-Based Programs and Practices, Office of Juvenile Justice and Delinquency Prevention, Model Program by Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention, Special Recognition from the Executive Office of the President Office of National Drug Control Policy, Promising Program by U.S. Department of Education, and selected to join the International Youth Foundation’s YouthNet.

Funding for this project was provided by the United States Department of Health and Human Services, Administration for Children and Families, Grant: 90FE0007. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the United States Department of Health and Human Services, Administration for Children and Families.