DHS Referral Form DHS Referral Form Name of Person to be Evaluated * Client Recipient ID# * Age/DOB * Gender * Client’s Primary Language * Names/Ages of Family Members * Biological Mother (no label) * Biological Father (no label) * Siblings (no label) * Significant Other With Whom Does The Child Live? * Foster parent/caregiver name(s) (no label) * Phone/Contact numbers (no label) * How long has the child been with current caregivers? Is the child in DHS custody? * Yes No If no, in whose custody? What SPECIFIC concerns do you currently have regarding the child? What SPECIFIC Questions Do You Want Addressed In the Present Evaluation? Current Functioning (intellectual, emotional, academic, developmental) Treatment or Special Services Needed Diagnosis Ability to Parent Strength/Bond of Relationship Long-term Placement Needs Ability to Transition to a Permanent Home Placement Considerations (e.g., residential treatment) Placement Considerations (e.g., residential treatment) Will Foster Parent/Caregiver Attend the Evaluation? * Yes No Who Will Transport the Child? * May We Make an Appointment Reminder Call? * Yes No Previous Evaluation/Testing? * Yes No If YES When and Where? What (if any) was the child’s most recent psychological diagnosis? Is the child currently in counseling? * Yes No If so, where and for how long? Is the child on prescription medication/s for a mental disorder? * Yes No Name of medications Does the child have any medical diagnoses? * Yes No If yes, what? Does the Child Have an IEP/504 Plan in school? * Yes No If yes, what is the IEP/504 for? What is the name of child’s school? Current grade How long has the child been in DHS care? Does the child have a history of documented physical abuse? * Yes No If yes, describe when and perpetrator Does the child have a history of documented sexual abuse? * Yes No If yes, describe when and perpetrator Has the child been formally examined for physical or sexual abuse? * Yes No If yes, when and by whom? Does child have visitation with biological parents, siblings, other relatives? * Yes No If yes, how often? (no label) Supervised Unsupervised Are there concerns related to any of the visitation? * Yes No If yes, please describe What Is the Current Permanency Plan For the Child ? * Do You Want a Parent/Child and/or Sibling Interaction? * Yes No How Many? Please list participants for EACH requested interaction: NOTE: More than two interactions will require additional office time. Would You Like to Schedule a Feedback Session Following the Evaluation? * Yes No If YES, By phone? In office? If YES, who will be in attendance in addition to the caseworker? Next Scheduled Court Hearing? (date) * Scheduling Constraints? (please be specific) PERMISSION to verify appointment with Translink-RVTD/Medical Transport-NEMT (or similar agency) if requested Caseworker * Branch * Phone * Fax * I AGREE TO RECEIVE THE COMPLETED REPORT VIA EMAIL * Yes No If Yes enter Email Address reCAPTCHA
