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Childcare Assistance | Rochester NY > Referral Request Form

Referral Request Form

General Information:

The information is intended for referral purposes only. We do not warrant the information concerning any provider, nor do we license, endorse or recommend any particular provider. Only you can determine whether the quality of care is appropriate for your child.

All information entered on this form is confidential. Click on this link to view our Confidentiality Policy .

If you do not receive information within two business days, please resubmit or call (585) 654-4720.

For more information concerning any program that may be of interest, please visit ocfs.state.ny.us or call the Office of Children and Family Services at (585) 238-8531.

Fields marked with an * are required in order to process your referral.
For the most accurate referrals, all fields must be completed.

Child Care Referral Request

  • Name of Person Needing Child Care Referral

  • Contact Information

  • Caseworker/Social Worker (if applicable)

  • Location Preferred for Child Care

  • Statistics of Person Requesting Child Care Referral

    A Referral Specialist will contact you with information on military fee assistance programs you might be eligible for. An enhanced referral service is available for Army and Marine Corps families.
  • Monroe, Wayne, and Livingston Counties have different financial assistance programs and different income ranges, some up to or above these numbers.

  • Status for County Child Care Subsidy

  • Referred to this service by:

  • Reason you are seeking child care or a change in child care:

  • Child One General Information

  • Type of Child Care Desired

  • Extra/Additional Care Services

  • Environmental Preferences

  • Languages Needed

  • Special Needs*

    *In order to better serve you, please explain in the additional comments

  • Additional Comments

  • This field is for validation purposes and should be left unchanged.

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