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CHS TIER 3 - CHILD REFERRALFORM
(eligibility criteria for referral listed at bottom)

Date Referred: / DOB:
Child’s Name: / Race:
Gender: / SIS#:

Family Finding:

Youth Referral for Tier 3:

Performance Outcomes (check ONE):

GOAL 1: / GOAL 2: / GOAL 3:
(Case plan of adoption): Firm commitment to adopt from at least 1 adult. Formalized written commitment signed by adoptive parent(s) and/or the child is placed in the prospective adoptive home. 12- 18 month timeframe. / (Case plan of guardianship or custody): Firm commitment to legal permanence from at least 1 adult. Guardianship/legal custody is transferred to the identified person by the court. 12- 18 month timeframe. / GOAL 3: Transfer of custody to relative/caretaker, DSS divested of their legal obligation to the child’s care. 12- 18 month timeframe.
DSS Social Worker: / County:
Work Address (Building Location):
Email / Telephone #: / Fax #:
Your preferred method of contact (check all options below):
Work number Cell phone (Please provide cell #) Email Does not matter (I check them all)
Supervisor: / Supervisor’s Phone #:
GAL name: / GAL phone # and/or email address:

Do parents retain legal rights? (select one):

YesNoTPRPending DON’T KNOW

Has this youth previously been adopted? (select one):

YesNoDON’T KNOW

Current Placement Information (check one):

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Home of Parent(s) – i.e. IN HOME

Home of Legal Guardian

Home of Relative

Therapeutic Home (MH/DD/SAS)

Dept of Juvenile Justice & Del Prevention

Residential School

Family Foster Care Home

Small Group Home (Residential)

Small Group Home (Treatment)

Children’s Camp

Specialized Family Foster Care Home (DSS)

Large Group Facility (Residential)

Large Group Facility (Treatment)

Hospital

Independent Living Arrangement

Adoptive Home (Non-relative)

Adoptive Home (Relative)

Adoptive Home (Foster Home)

Maternity Home

Jail, Lock-up, Detention Facility

Emergency Shelter

Family Foster Home, Relative

Specialized Family Foster Home, Relative

Trial Home Visit

Runaway

Respite

Other:

DON’T KNOW

NOT APPLICABLE

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If child is in out-of-home placement only: Length of time in current placement setting:

If not known, please estimate length of time (select one):

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Less than 1 month

1-6 months

7-12 months

1-3 years

4-6 years

Over 6 years

Not Involved

DON’T KNOW

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Length of time since child’s family (including child or child’s siblings) first became involved with DSS (including earliest time of any investigation or in-home services):

The family of child’s mother or father ever involved with DSS when the mother or father was a child (select one):

YesNoDON’T KNOW

Current Case Plan (check one):

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Adoption

Custody with non-removal Parent or Relative

Custody with other court approved caretaker

Guardianship with Relative

APPLA

Emancipate

Court approved caretaker

Family Reunification

Plan Goal not yet established

Prevention

Other:

DON’T KNOW

NOT APPLICABLE

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Name of siblings(First & Last) / Referred Also (Y/N)
*If yes, complete separate referral form for each sibling. / Living with child (Y/N)

Number of Relative and Adult Connections known at referral:

If exact number is not known, please estimate number of connections (select one):

None1-3 4-89-10More than 10DON’T KNOW

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Relative(s),other than birth parents, ever previously involved in case planning (e.g., attended a family group decision-making meeting or attended a court hearing) (check one):

YesNoDON’T KNOW

Child needs or uses more services than is usual for most children of the same age:

Medical care (check one):YesNoDON’T KNOW

Mental health services (check one): YesNoDON’T KNOW

Educational services (check one):YesNoDON’T KNOW

Child ever been arrested by the police or taken into custody for an illegal or delinquent offense (do not include arrests for minor traffic violations) (check one):

YesNoDON’T KNOW

Safety Concerns
Running Away/ Missing / Severe risk: Moderate risk: Low risk:
Self Harm / Severe risk: Moderate risk: Low risk:
Harm to Others / Severe risk: Moderate risk: Low risk:
Other / Severe risk: Moderate risk: Low risk:
Specify nature of risk:

What is the most important thing for the Children’s Home Society worker to know about this child and his/her circumstances and experiences?

Did you consider referring this child to services or a program other than the service selected above to aid with the search and engagement of relatives/adult connections or at achieving permanency?

YesNo DON’T KNOW

If yes, please list those programs or services:

What, if anything, drove your decision to refer this child for these services, above and beyond the basic eligibility criteria?

Comments: