DFCS Services Referral

DFCS Date of Referral: Date Received: County Workers Name: Phone Number: Email: Family Name: Phone Number Address: Names and DOB of Family Members: Reason For Referral: Child Protective Services/ Ongoing: Early Intervention ( 551-79b) Parent Aide Services ( 573-72h) Homestead (571-61a) (In-Home) Psychological (521-51-54-PUP) Assessments (521-52-PUP) (Parental Fitness, Substance, Anger) Drug Screen (521-51b) (urine) Drug Screen (521-51a) (hair follicle) SafeCare / Family Visitation Services (573-63d) Fast Track: Other If other please specify here: Placement Services/Wrap-Around: (check all that apply) Home Evaluation ( 511-29a) Comprehensive Child and Family Assessment (CCFA) (511-29a-29o) Transportation (518-56a) Crisis Intervention/ Prevent Disruption Clinical (518-24a) Crisis Intervention/ Prevent Disruption Para (518-24b) Crisis Intervention Behavioral Clinical (518-47a) Crisis Intervention Behavioral Para (518-47b) In-Home Case Management Clinical (518-71a) In-Home Case Management Paraprofessional (518-71b) In-Home Intensive Clinical/Therapuetic (518-95a) Court Appearance and/ or Testimony (518-88a/b) Case Planning Is there a safety plan? Yes No Is there a case plan? Yes No FTM Date: MDT Date: Panel Review Date: Are Services Court Ordered? Yes No Date of next Hearing Court Pt CASA Worker: Other Service Providers? Yes No Prior DFCS History? Yes No Language Spoken Any alcohol or drug abuse suspected? Yes No Drug of Choice If yes, who’s using, what are they using? What concerns should be addressed? Supervisors Name: First Last Phone Mobile Email Upload Shines authorizations here for online referrals*

Rate Sheet for SHINES Downloadable Referral Form Download CCFA referral Click HERE to Download Brochure Download Information Flyer

 *Please Ensure All Shines Authorizations Are Attached To This Referral*

Complete On-line or  Fax to: 678-460-0350 

Email: DFCSreferrals@Familytiesinc.com