CSO-1029A (8-14)
(CPS-1017A (8-11) / ARIZONA DEPARTMENT OF CHILD SAFETY

NOTICE REQUESTING IN-HOME INTERVENTION

Arizona laws [A.R.S.§ 8-456(C) and (D); 8-471 (E)(4)(b)] require the Department of Child Safety to:

  • make a prompt and thorough investigation to evaluate the nature, extent and cause of any condition created by the parent, guardian, custodian, or adult member of the household that would tend to support or refute the allegation that the child is a victim of abuse or neglect and determine the name, age and conditions of other children in the home, and
  • after investigation, determine whether any child is in need of child safety services and, if appropriate, offer reunification services designed to correct the unresolved issues.

This notice is to inform you that DCS has completed its investigation concerning your family and has assessed the child to be at risk of harm requiring services to maintain the child’s continued safety and well-being in the home. The assessment has identified risk factors that appear likely to be resolved with In-Home Intervention and services with Court oversight. DCS will file a legal paper with the Court, called a Dependency Petition, requesting an In-Home Intervention. The Petition will describe the need for Court oversight, the reason in-home services under a dependency are necessary, your agreement to a case plan and participation in services, and recommend the children be made temporary wards of the court and remain in your home. The Juvenile Court will make the final decision regarding the placement of the children.

NAME OF CHILD
NAME OF CHILD
NAME OF CHILD
NAME OF CHILD
REASON AN IN-HOME DEPENDENCY PETITION IS NECESSARY

When a petition is filed, you have the right to have an attorney represent you. The Juvenile Court will appoint an attorney to represent you if you qualify financially. The court may also appoint an attorney or a guardian ad litem to represent your child’s best interest. You must meet with your attorney. You have the right to give a verbal or written response to the allegations and have them included in the investigation report. Any documentation you give and what you say or write will be included in the case record and can be used in Court proceedings. It is your responsibility to participate in services as determined reasonable and necessary by the Court.

The In-Home Intervention shall include a specific time for completion of services, which shall not exceed one year without review and approval by the Court.The Court shall dismiss the Dependency Petition if the specific time for completion of the In-Home Intervention has expired without being extended by the Court, and a dependency adjudication hearing has not been set. If the parent, guardian or custodian violates the In-Home Intervention order, the Court may take whatever steps are necessary to obtain compliance or may rescind the order and set the dependency adjudication hearing.

DCS REPRESENTATIVE’S NAME (Print) / PHONE NO. (Include Area Code)
DCS REPRESENTATIVE’S SIGNATURE
ARIZONA DEPARTMENT OF CHILD SAFETY’S ADDRESS (No. Street, City, State, ZIP)
I explained In-Home Intervention, reviewed and served this notice to (parent, guardian or custodian):
on (date): / at (time): / AMPM

Are you or your child of American Indian heritage/ancestry?Yes NoUnknown

PARENT, GUARDIAN OR CUSTODIAN’S NAME (Print)
PARENT, GUARDIAN OR CUSTODIAN’S SIGNATURE

See reverse for EOE/ADA/LEP/GINA disclosures

Information for Parents, Guardians and Custodians

PURPOSE: This form is to inform you, the child’s parent, guardian or custodian that DCS has completed an investigation and intends to file a Dependency Petition Requesting In-Home Intervention with the Juvenile Court. An In-Home Dependency Petition is a paper that explains to the court the results of the investigation and why:

  • a Dependency Petition requesting In-Home Intervention is necessary;
  • DCS is recommending the a child be made a temporary ward of the Court, placed in the care, custody and control of the Arizona Department of Child Safety and remain in the home.

You may call the Parent Assistance Statewide Hotline, 1-800-732-8193, or Phoenix (602) 542-9580, for more information on the Juvenile Court system and how to obtain legal assistance.

You have the right to call the Office of the Ombudsman-Citizen’s Aide, if you have a complaint about DCS actions. The Ombudsman-Citizen’s Aide will impartially investigate the complaint, inform you of the results of the investigation and provide you with referrals for additional assistance. To contact the Ombudsman-Citizen’s Aide call: 1-800-872-2879, or Phoenix (602) 277-7292.

You have the right to have an attorney represent you. The Juvenile Court will appoint an attorney to represent you if you qualify financially.

Services and Programs

Services provided are child-centered and family-focused to promote family preservation, independence and self-sufficiency. Programs available include, but are not limited to:

In-Home Services: Directed at strengthening the family unit to enhance parenting skills including:

  • Intensive family preservation
  • Parent aide services
  • Parent skills training
  • Child care
  • Referrals to community services
  • Counseling/Psychological evaluations
  • Drug and/or alcohol treatment programs
  • Services to high-risk infants and their families
  • Families First Program

  • Other :

The Arizona Department of Child Safety is referring you to the following services:

Additional service needs will be assessed prior to the Initial Hearing.

COMPLETION AND DOCUMENTATION:

This notice must indicate:

  • the date and time that the notice was reviewed and served to the parent, guardian or custodian;
  • the reason an In-Home Dependency Petition Requesting In-Home Intervention is necessary;
  • the Child Safety Specialist’s name, phone number, and address of the local DCS office; and
  • the signature of the parent, guardian or custodian. If he/she refuses, write in “Refuses to Sign” on the signature line. Leave a copy of the form with the parent, guardian or custodian even if he/she refuses to sign.

DISTRIBUTION: Acopy is given to the parent, guardian or custodian;a copy is retained in the case record.

RETENTION: A copy of the form is retained in the permanent case record.

Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact 602-542-3598; TTY/TDD Services: 7-1-1. • Free language assistance for department services is available upon request. • Disponible en español en línea o en la oficina local.