Project SOOTHe Request Form

***if you are a caseworker or CASA worker submitting the form for a caregiver, please be sure to input the CAREGIVER'S First Name, Last Name, Email Address, and Phone Number in the fields immediately below this section. Then, input your information (as a caseworker) in the section halfway down the page.

Your name *

Last name

Email address *

Phone number *

Phone type

I consent to receive updates & communication from Foster Village Austin *

Preferred Method of Communication *

Call

Text

Can we follow up?

How did you hear about Project SOOTHe?

From the Foster Village Request Follow-Up Email

On Social Media

Word of mouth

From the Foster Village Newsletter

Google Search

Other

Would you like a delivery or pickup? *

We are located at 10545 Dessau Rd, Austin, TX 78754 if you would like to come pick up.

What type of family is this request for? *

County of Placement *

County of Case *

Are you the primary caregiver for the children? *

Please Provide the Name of the Assigned CPS Caseworker or Licensing Agency *

Please Provide An Email Or Phone Number for the Assigned CPS Caseworker or Licensing Agency *

Notes *

Items Requesting *

It is not required that you select all items listed below, please only request items that are needed. However, If you need multiples of a single item, please let us know in the notes section below.

Weighted Items (e.g. blanket, lap pad, stuffed animal)

Sensory Toys

Therapeutic Swing

Sound Machine

I'm not sure

Other

We'd love to know more about the child.

How many children are in the home? *

Child's likes, dislikes, favorite color, etc. *

Child's age *

Child's approximate height

Child's approximate weight

Please verify that the name at the top of the form is the CAREGIVER'S first and last name. *

If you are a Case Manager or CASA volunteer submitting for one of your families, do NOT type your name in the field at the very top of the form. Your name goes in the field that says, "Please Provide the Name & Contact Info for Licensing Agency and/or Assigned CPS Caseworker."

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Foster Village Austin

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