/ Tennessee Department of Children’s Services
Placement Stability Referral and Checklist

This form is used to make placement referrals after a Placement Stability Child and Family Team Meeting.

Child/Client Information
Name / SSN / / /
DOB / Sex / MaleFemale / Race / American Indian/Alaskan NativeAsianBlack/African AmericanHawaiian/Pacific IslanderWhiteUnable to Determine Race
Removal Date / Legal Custody Date / County
Worker’s Name / Supervisor’s Name
Is child of Native American Descent / Yes No Unable to Determine / If “Yes” Tribal Affiliation
Where was child born? / City / County / State / Country
Is child a U.S. Citizen? / Yes No / Does child have any children? / Yes No
Child’s Marital Status (check one) / Never Married Divorced Widowed Married Separated
Family’s Religious Preference
Photos taken by worker / Yes No / Receiving Adoption Assistance / Yes No
Removal Street Address
City / County / State / Zip Code
Client ID #
Adjudication Type / Dependent and Neglect Unruly Delinquent N/A
Placement Needs
Emergency / Placement Stability/ Disruption
Step-Down / Return from Runaway
Emergency
Services / Temporary Shelter
PrimaryTreatmentCenter (PTC) / Detention
Emergency Foster Care
Program
Services / Level I Services:Foster Care Independent Living / Interstate
Level II Services:CongregateTherapeutic Foster Care
Special NeedsSpecial Population Special Population (A&D) / Interstate
Level III Services:ResidentialTherapeutic Foster Care
Special NeedsSpecial Population Special Population (SO) / Interstate
Medically Fragile Foster Care / Completed forms CS-0715 and CS-0716 attached / Yes No / Interstate
Level IV Services
YouthDevelopmentCenter (YDC)
Education Information
Grade/DateStarted / CurrentSchool
School Child Last Attended
Special Education Needs
Medical Information
Primary Care Physician / Last Date of Medical Exam
Address
Physical Health\Diagnosis
Is child taking any medications? / Yes No / Does child have three (3) day supply ofmedications? / Yes No
List all medications and dosages
Child’s disabilities
Additional Well-Being Information
Counselor/Therapist Examiner / Date(s)
Patient/Client
Nature of Counseling/Testing
IQ / Full Scale / Verbal / Date of Test
Adaptive Level of Functioning / Date of Test
Axis I / Axis II / Axis III / Axis IV / Axis V
Recommendations From Counselor\Therapist
Family Service Worker
Name / Telephone / () -
Please contact / at / He/she will be transporting the child(ren).
Review Signature
Supervisor / Telephone / () - / Date
Verbal approval received from Supervisor / Yes No
Approving Supervisor’s name
Referral Packet Information
Cover Letter
Placement Referral
Custody/Guardianship Order
Family Functional Assessment (current within 3 months)
CFTM Summary (CS-0747) in cases where Placement Stability Meeting has been held
Critical Medical/Medication Information (i.e., Current Dental information, EPSDT [if complete], immunization records, completed forms CS-0543 Well Being Information and History, CS-0206 Authorization for Routine Health Services for Minors, etc.)
Education Passport (with all attachments. Include any “zero tolerance” issues that may exist)
Psychological Assessment (if appropriate)
A CompletePermanency Plan packet including any revisions - Items include:
The Permanency Plan, Notice of Equal Access to Programs, TennCare Medical Appeal, Notice of Action and Notice of Termination Procedures.
Social Security Card
Birth Certificate
TennCare Card
Discharge Summary (when applicable)
Community Risk Assessment (when applicable)

Agencies should admit emergency referrals without referral packets or with incomplete referral packets with information forwarded immediately as available by regional staff. All agencies are required to provide to their respective program coordinators in the DCS Child Placement and Private Provider Division emergency contact information for their gatekeeper. The gatekeeper must be available 24/7 and must be empowered to make placement decisions. (Pg. 49, Ch. 1, Sec. III, O., 2 – Provider Policy Manual)

To be completed by Residential Providers ONLY-Please Return by Fax to / () -
Accepted / Admission Approved by
Date of Arrival / Expected Arrival Time / A.M. / P.M.
RejectionDate / Reason for Denial / Cannont meet transportation needsCannot meet educational needsRisk score too highRefuses to work with a specific DCS regionChild's runaway historyChild's history of disruptive behaviorChild's home county is too far awayDisagree with requested level of careNo Vacancies - at CapacityChild is inappropriate for the current milieuIncomplete packetNo resource home matchBehavior/needs too severe Current unsafe milieu for new admissionChild has been placed on tthe waiting list
Denied for Other Reasons (Specify)

Always check the “Forms” Website for most current version. This form may not be altered.

Distribution: Child/Youth Case File and Private Provider

CS-0743, Rev. 11/07Page 1 of 3