Family Connection
Internal Staff Referral
Referral Source
I am a parent/caregiver contacting you about a family member
I am a professional contacting you about a family
I am a self-advocate or youth contacting you about myself
Professional Information
First Name
Last Name
Organization (Please be specific)
Email
Phone Type
Please select...
Work
Mobile
Mobile Phone
Work Phone
Contact Information
First Name
Last Name
Email
Phone Type
Please select...
Work
Mobile
Home
Mobile Phone
Home Phone
Work Phone
Mailing Street
Mailing City
Mailing State
Mailing Zip
Primary Language
Please select...
English
Spanish
Other
Other Language
County
Please select...
Abbeville
Aiken
Allendale
Anderson
Bamberg
Barnwell
Beaufort
Berkeley
Calhoun
Charleston
Cherokee
Chester
Chesterfield
Clarendon
Colleton
Darlington
Dillon
Dorchester
Edgefield
Fairfield
Florence
Georgetown
Greenville
Greenwood
Hampton
Horry
Jasper
Kershaw
Lancaster
Laurens
Lee
Lexington
Marion
Marlboro
McCormick
Newberry
Oconee
Orangeburg
Pickens
Richland
Saluda
Spartanburg
Sumter
Union
Williamsburg
York
Out of State
Child/Person with Disability Information
First Name
Last Name
Birthdate
Primary Diagnosis/Disability
Race
Please select...
Hispanic/Latino
Caucasian/White
African-American/Black
American Indian/Native American/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
Two or more races
Prefer not to answer
Child's school information
Child is not in school
Childcare
Child is in school
School District
Please select...
Abbeville
Aiken
Allendale
Anderson 01
Anderson 02
Anderson 03
Anderson 04
Anderson 05
Bamberg
Barnwell 45
Barnwell 48
Beaufort
Berkeley
Calhoun
Charleston
Charter Erskine
Cherokee
Chester
Chesterfield
Clarendon
Colleton
Darlington
Dillon 03
Dillon 04
Dorchester 02
Dorchester 04
Edgefield
Fairfield
Florence 01
Florence 02
Florence 03
Florence 05
Georgetown
Greenville
Greenwood 50
Greenwood 51
Greenwood 52
Hampton Consolidated
Horry
Jasper
Kershaw
Lancaster
Laurens 55
Laurens 56
Lee
Lexington/Richland 05
Lexington 01
Lexington 02
Lexington 03
Lexington 04
Limestone Charter
Marion
Marlboro
McCormick
Newberry
Oconee
Orangeburg
Palmetto Unified
Pickens
Richland 01
Richland 02
Saluda
SC Department of Juvenile Justice
SC Governor's School for Agriculture at John de la Howe
SC Governor's School for Science and Mathematics
SC Governor's School For The Arts and Humanities
SC Public Charter
SC School of Deaf & Blind
Spartanburg 01
Spartanburg 02
Spartanburg 03
Spartanburg 04
Spartanburg 05
Spartanburg 06
Spartanburg 07
Sumter
Union
Williamsburg
York 01
York 02
York 03
York 04
Other
School Name
Current Grade
Please select...
Childcare/Daycare
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
beyond high school
Please provide us with as much information as possible about your current concerns regarding the child's health and well-being.
Submitted By (FCSC Staff Name):