FSW Name FSW Office Phone FSW Cell Phone

/ Tennessee Department of Children’s Services
Termination of Parental Rights Referral

Contact the local Child Support Enforcement Office. Tell them who you are and that you need to know a) whether support has been established on the parent for each child, and b) whether any payments have been made. Ask them nicely to fax you any orders setting support, orders holding a parent in contempt, and a payment history for each parent. Have the children’s names and dates of birth and the parents’ names and social security numbers handy as they usually request that information. Ask them for the TCSES number for each parent’s case.
Contact the jails in each county where you think the parent may have been incarcerated. Ask the jail administrator to fax you a print-out of the parent’s dates of incarceration (as far back as they can go is best, but make sure it at least covers the time the child has been alive.) Some counties are now asking for a letter on letterhead to be faxed to them first, so be prepared to put that request in writing if needed.
If the parent has a criminal history, go to the circuit court clerk’s office in each county where you know they have had legal charges and ask for a certified copy of their criminal convictions (not just a history of their charges and dispositions). Make sure you have the parent’s full name, date of birth, and social security number on hand. Make sure the clerk is giving you their convictions out of both general sessions and criminal courts.
Study the complete file on the family. Read case recording for all case mangers assigned to the case. Read service provider records. Gather any missing service provider records. Make notes or tab significant information. If there have been previous removals of the children from the parents, gather those old files and review them. The fact that you have recently been assigned to the case will not be accepted as an excuse for not knowing the case and not being able to provide the necessary information to the DCS attorney to draft the TPR petition. Do not submit this Request if you have not gone through the entire file.

requests an appointment

to draft a TPR petition on the following case. The county of legal venue is / .

I have attached the required documents (see checklist on last page) and will bring the entire case file to the

appointment and have all the additional required documentation set out in the attached list at the time of

the appointment.

List children’s full names and dates of birth. Only include full and half siblings. Please be sure to spell the names correctly. LONG FORM Birth Certificate(s) attached

Child Name / DOB
Child Name / DOB
Child Name / DOB
Child Name / DOB
Child Name / DOB
Child Name / DOB
Child Name / DOB
Child Name / DOB
Child Name / DOB
Child Name / DOB

BIO/LEGAL/PUTATIVE PARENT INFORMATION

List mother’s full name, including maiden name, date of birth and verified address.

*If address isn’t verified please bring last known address. If unable to locate bring affidavit of diligent search.

Mother’s Full Name / DOB / Address

List all fathers’ full names, dates of birth and verified address.

*If address isn’t verified please bring last known address. If unable to locate bring affidavit of diligent search.

Child 1 Name:
Biological Father’s Full Name / DOB / Address
Legal Father’s Full Name / DOB / Address
Putative Father’s Full Name / DOB / Address
Child 2 Name:
Biological Father’s Full Name / DOB / Address
Legal Father’s Full Name / DOB / Address
Putative Father’s Full Name / DOB / Address
Child 3 Name:
Biological Father’s Full Name / DOB / Address
Legal Father’s Full Name / DOB / Address
Putative Father’s Full Name / DOB / Address

* If there are additional children who do not share a father, please list them on an additional sheet of paper.

List date(s) of marriage (both mother and father) and complete with name(s) of spouse(s)

Date of Marriage / Name of spouse
Date of Marriage / Name of spouse
Date of Marriage / Name of spouse

List date(s) of divorce (both mother and father) complete with name(s)

Date of Divorce / Place of Divorce / Name of spouse
Date of Divorce / Place of Divorce / Name of spouse
Date of Divorce / Place of Divorce / Name of spouse

CUSTODY INFORMATION

Date of this custody episode:
County and/or state if not Tennessee:
Date of adjudication:
Date(s) ofall previous custody episode(s):
Brief summary of allegations that brought the child(ren) into custody:

DATES OF PERM PLANS

Date of Plan: / Date of Ratification: / Goal(s):
Date of Plan: / Date of Ratification: / Goal(s):
Date of Plan: / Date of Ratification: / Goal(s):
Date of Plan: / Date of Ratification: / Goal(s):
Date of Plan: / Date of Ratification: / Goal(s):
Date of Plan: / Date of Ratification: / Goal(s):

DATES FOR CRITERIA AND PROCEDURES FOR TPR

Dates Criteria were signed by mother:
Dates Criteria were signed by father (Name):
Dates Criteria were signed by father (Name):
Dates Criteria were reviewed by CM with mother:
Dates Criteria were reviewed by CM with father (Name):
Dates Criteria were reviewed by CM with father (Name):
Dates Criteria were mailed to mother:
Dates Criteria were mailed to father (Name):
Dates Criteria were reviewed by the Court with mother:
Dates Criteria were reviewed by the Court with father (Name):
Dates Criteria were reviewed by the Court with father (Name):

Criteria and Procedures for TPR or Affidavit of Presentation attached

DATES OF INCARCERATIONS

was incarcerated from / to / In the
Jail for

We need to know ALL DATES, PLACES AND REASONS FOR INCARCERATION FOR ALL PARENTSsince the child entered custody. Please attach additional sheets as necessary to make sure that all incarcerations are listed.

Copy of In and Out Report attached

PARENTAL SURRENDERS

surrendered all parental rights to the child(ren),
Before the Honorable
, judge of the / Court of
County, Tennessee or Warden, / on / and did not

revoke said surrender(s).

PARENTAL DEATHS

died on / in
County, TN or / other state.

Death certificate attached

WAIVER OF INTEREST

signed a Waiver of Interest regarding the child(ren),
on / .

Waiver attached

LEGAL FATHER’S WAIVER OF PATERNITY

signed a Waiver of Paternity regarding the child(ren),
on / .

Waiver attached

THE FOLLOWING GROUNDS FOR TPR MAY EXIST:

Failure to Pay Child Support

has abandoned the child(ren) by knowingly failing to support the child(ren)

in the last four months (or four months prior to their incarceration) or only providing token support. DATES AND AMOUNTS OF SUPPORT FOR EACH PARENT IN THE LAST FOUR MONTHS:

Include documentation regarding parent(s) employment or ability to work and list employment history

TCSES screen attached

Copy of Child Support Order (if applicable)

FAILURE TO VISIT

has abandoned the child(ren) by knowingly failing to visit the
child(ren) in the last four months (or four months prior to their incarceration) or only having token
visitation.

DATES OF VISITS FOR EACH PARENT IN THE LAST FOUR MONTHS OR DATE OF LAST VISIT IF LONGER THAN FOUR MONTHS:

Failure to Establish Suitable Home in theFirst Four Months

Mother Father Both

Date removed from parent:

Was child removed from both parents? Yes No

What did parent do to try to provide a suitable home in the first four months after removal?

Have they done anything since that time?
What reasonable efforts did DCS provide to assist them?
Why is their home not suitable?

INCARCERATED PARENT

who is/are curently incarcerated or was

incarcerated in the four months preceeding the filing

Mother Father Both

SENTENCE INFO (LENGTH OF TIME AND CONVICTION):

In the four months BEFOREparent went to jail, did the parent fail to visit or fail to support (or both) the child? Yes No

Date of last visit:
Date and amount of last support payment:
If failure to support, include child support order info:

Did parent exhibit a wanton disregard for the welfare of the child? Yes No

Explain:

SUBSTANTIAL NON-COMPLIANCE WITH PERMANENCY PLAN

has/have not substantially complied with

the Permanency Plan(s). Parent(s) has/have not completed or maintained the following:

Perm Plan(s) attached

PERSISTENCE OF CONDITIONS

The child(ren) was/were removed from the home of

by an order of the court more than six months ago and the conditions that led to the removal of the

child(ren) from the home still exist or other conditions exist that in all reasonable probability cause the

child(ren) to be subject to further abuse or neglect, therefore preventing safe return. There is little

likelihood these conditions could be remedied at an early date so the child(ren) could be safely returned in

the near future. The continuation of the parent and child relationship greatly diminishes the child(ren)’s

chance of early integration into a safe, stable and permanent home.

Conditions that led to removal:
Conditions that prevent return:

SEVERE CHILD ABUSE

has/have committed severe child abuse against
who isthis child a sibling half-sibling of this child or

another child who lived in the home of the parent(s). The conduct that constitutes severe abuse was:

Explain:

Attach any orders adjudicating severe abuse if applicable

SENTENCED TO MORE THAN TWO YEARS IMPRISONMENT FOR CHILD ABUSE

has/have been sentenced to more than two years
imprisonment for child abuse against / .

Criminal conviction attached

Criminal offense and date:
has/have been convicted for trafficking for

commercial sex act under § 39-13-309.

Criminal conviction attached

Criminal offense and date:

TEN YEAR SENTENCE WHEN CHILD IS LESS THAN EIGHT YEARS OLD (CAN BE MORE THAN ONE SENTENCE THAT ADDS UP TO AT LEAST 10 CONSECUTIVE YEARS)

has/have been sentenced as a result of a criminal

act, under a sentence of ten (10) or more years and the child(ren) who is/are the subject of this Petition was/were under eight (8) years of age at the time the sentence was entered by the Court.

Criminal conviction attached

Convicted offense and date:

WRONGFUL DEATH OF OTHER PARENT

has been convicted of or found civilly liable for the

Intentional and wrongful death of the child(ren)’s other parent or legal guardian.

Criminal conviction or civil order attached

INCOMPETENCE

Is/are incompetent to adequately provide for the

furthercare and supervision of the child(ren) because their mental condition is presently so impaired and is so likely to remain so that it would be unlikely that they will be able to assume or resume the care of and responsibility for the child(ren) in the near future.

Psychological or Psychiatric Evaluations showing incompetency to parent attached

PUTATIVE FATHER’S FAILURE TO ESTABLISH PARENTAGE

THIS GROUND DOES NOT APPLY TO ANY MAN WHO:

Was married to the child’s biological mother at the time of the child’s birth or 300 days before the child’s birth,
attempted to marry the child’s biological mother,
has been adjudicated by a court to be the father of the child,
has signed a voluntary acknowledgement of paternity,
has adopted the child, or
is listed on the birth certificate.

has failed without good cause or excuse, to make

reasonable and consistent payments for the support of the child(ren) in accordance with the child support

has failed to seek reasonable visitation with the

child(ren), and if visitation has been granted, has failed to visit altogether, or has engaged in only token

visitation.

has failed to manifest an ability and willingness to

assume legal and physical custody of the child.

Placing the child in the custody of / would pose a risk of

substantial harm to the physical or psychological welfare of the child(ren).

has failed to file a petition to legitimate the child(ren)

within thirty (30) days after notice of alleged paternity or after the father(s) made a claim of paternity.

How and when did putative father get notice of alleged paternity?

LEGAL PARENT’S UNWILLINGNESS TO ASSUME CUSTODY (MUST BE A LEGAL PARENT NOT PUTATIVE! SEE ABOVE FOR DEFINITION OF LEGAL PARENT)

has failed to manifest, by act or omission, an ability

or willingness to personally assume legal and physical custody or financial responsibility of the child(ren); AND,

Placing the child(ren) in the legal and physical custody of

pose a risk of substantial harm to the physical or psychological welfare of the child(ren).

BEST INTERESTS

has/have not made an adjustment of circumstances,

conduct or conditions as to make it safe and in the child(ren)’s best interest to be in the home.

has/have failed to effect a lasting adjustment after

reasonable efforts by available social agencies for such duration of time that lasting adjustment does not

reasonably appear possible.

Explain services offered and parents’ failures:
has/have not maintained regular visitation or other

contact with the child(ren).

Dates of last visit for each parent:
A meaningful relationship has not otherwise been established between the child(ren) and
Explain:
A change of caretaker and physical environment is likely to have a negative effect on the child(ren)’s
emotional, psychological and/or medical condition. / Explain:
has/have committed brutality, physical, sexual,

emotional or psychological abuse or neglect toward other child(ren) in the family or household.

Explain:
A person residing with / has committed brutality, physical,

sexual, emotional or psychological abuse or neglect toward other child(ren) in the family or household.

Explain:
The physical environment of the home of / is unhealthy and/or
unsafe for the child(ren). / Explain:
There is criminal activity in the home of / .
Explain:
use of alcohol or controlled substances renders

him/her consistently unable to care for the child(ren) in a safe and stable manner.

Explain:
mental and/or emotional status would be

detrimental to the child(ren) and/or prevent him/her from effectively providing safe and stable care and

supervision for the child(ren).

Explain:
has/have not paid child support consistently

with the child support guidelines.

has/ have not paid a reasonable portion of the

children’s substitute physical care and maintenance when financially able to do so. [For example: The

parent has not provided any (or a significant amount of) food, clothing, diapers, toiletries, school supplies,

books, toys, etc.].

has/ have shown little or no genuine interest

in the welfare of the child(ren).

continue(s) to make lifestyle choices that prevent

him/her/them from being able to parent the child(ren) or to provide a home for the child(ren).

The child(ren) is/are placed in a foster home that wishes to adopt the child(ren).

List context of home, names, how long the child(ren) have been placed there:

The child(ren) has/have established a strong bond with the foster parents.

The child(ren) has/have expressed a desire to have parental rights terminated so that he/she/they can

be adopted.

The child(ren)’s mental health counselor has opined that it is in the child(ren)’s best interest to establish

permanency for the child(ren) as soon as possible through adoption.

Which child? / Counselor:

Report attached

The child(ren) need(s) to be released from the stigma of being (a) foster child(ren)

List other facts that show it is in the child(ren)’s best interest to terminate parental rights, including any

special needs the child has:

I have reviewed this document and agree the case is ready for TPR and the FSW has all the information and documentation necessary to meet with legal to draft the TPR Petition. I have reviewed this request for Appointment to Draft TPR and believe it is adequately completed and I have confirmed that the following documents are attached to this request if applicable to this case. Items with * must be attached to all requests.

All children’s LONG FORM birth certificates* (Do not submit this request if you only have the short form birth certificate.)
Surrenders
DNA tests
Parental death certificates
Putative father Waiver of Interest
Legal father’s Waiver of Paternity
Divorce Decree (if applicable)
All Permanency Plans*
Current Affidavit of Reasonable Efforts that is chronological, detailed and date specific*
All signed Criteria and Procedure for Termination of Parental Rights*
Affidavit of Presentation or Perm Plan and Criteria for TPR whenever parent does not sign Criteria
Certified Criminal Convictions for child abuse with two year sentence
Certified Criminal Conviction with 10 year or longer sentence when child under 8 when sentenced
Certified Criminal Conviction or civil order for wrongful death of other parent
Psychological evaluation showing parent is incompetent to parent child
Certified Child Support Orders (if any exist)
Case Manager’s Signature / Date
Team Leader/Coordinator’s Signature / Date

ITEMS THAT MUST BE BROUGHT TO MEETING TO DRAFT TPR IF APPLICABLE