Intensive In-Home Service Referral

Concerns for in-home worker safety: Yes No
Explain: / Referral Date: Time: AM/ PM
Region:
Case Name:
Reason for referral:  Prevention of out of home placement
 Reunification (Child must be in the home within 7 days)
 Stabilization of a Relative or Long-Term Placement
Address: / City: / State: / Zip Code:
Phone Number(s): ______
(Home) (Cell) (Work)
Mother: / Address (if different):
Father: / Address: (if different):
Other Adults Living in the Home and Relationship:
______
______
______
Child’s Name / DOB / Race / Living at Home
Yes No / At Risk of Placement
Yes No
Name(s) and Address(s) of any children not living in the home:
______
______
______
______
Describe the specific Imminent Situation and Imminent Risk to Child(ren):
______
______
______
Which of the following describes the issues necessitating referral to Continuum Care?
Physical Abuse Sexual Abuse
Neglect: Medical Lack of Supervision
Domestic Violence Substance Abuse Mental Illness Inadequate Shelter Other ______
Transition into the home
Evident Strengths of Family: ______
______
______
Current Juvenile Court Involvement: Yes No
Other Pertinent Information: ______
______
______
Referring Worker’s Goals for the Family:
Child development education  Substance abuse treatment
Parenting  Housekeeping
Discipline Supervision
Family Communication  Money Management
Attachment/Bonding  Safety
Other ______
Please explain reason for the above goals: ______
______
______
Justification for Intensive Home-based Services:
I have reviewed and determined that if Continuum Care does not accept this case, one of the following willlikely occur within 72 hours:
PlacementDisruption in Foster Home
Delay in Reunification
Delayed Move to Less Restrictive Placement
Is this family willing to participate with Continuum Care? Yes No

Signatures:

DSS/FC/DJJ/ Other Worker:
Date: / Office Phone:
After Hours Phone:
Supervisor: Date: Telephone Number:
Reviewed By: Date:
Intake Coordinator and/or Executive Director
*****************************************************************************************************************
TO BE COMPLETED BY CONTINUUM CARESERVICES, INC.
Accepted:  Yes  No
If No, Reason: Safety Issues/Risks Too High  Appropriate for more extensive service
Other
______
______
Assigned Continuum Care Therapist: Phone #: ______
After Hours #: ______
*****************************************************************************************************************
Attachments:
 Case Plan
 Investigative Summary
 Social History/Assessment
 Psychological/Psychiatric Evaluation
 Other ______

1

Case Name:

Continuum Care Services, Inc. CCS Form

P.O. Box 6331 Revised 3/15/2008

Concord, NC28027