REFERRAL FORM. Referral Source Information. Docket Number: Date that petition was filed:

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1 REFERRAL FORM Referral Criteria: Child must be under 3 years old at the time of referral The permanency goal must be reunification The referred parent must be a respondent on the case No order of protection between the referred parent and referred child Both the parent and referred child should reside in the Bronx or upper Manhattan Please remember to: Attach ACS petition or Summarized Addendum Attach relevant parent and child psychological, educational evaluations. Call to confirm receipt of referral Please complete all sections and fax to (718) Date of referral: Referral Source Information Name of Referral Source: Telephone number: Fax number: This referral was requested by a Judge: Yes No This referral is made by a: Foster Care Agency Caseworker ACS Caseworker ACS Attorney Child s Attorney Parent s Attorney Other, Please describe: Docket Number: Date that petition was filed: Type of Petition: Abuse Neglect Stage of Proceeding: Pre-Fact Finding Fact-Finding Pre-Dispo Post-Dispo Permanency Goal is reunification? Yes No Family Court Judge: Next Court Date, Purpose and Location:

2 Referred Parent Information Referred Parent (s): Referred Parent DOB: / / Has referred parent undergone a mental health evaluation? Yes No (If yes, please attach) Referred Parent s Dominant Language: English Spanish Other: Referred Parent Ethnicity: Referred Parent Address: Referred Parent Contact numbers: or Relevant background information on Biological Referred Parent(s) : History of substance abuse, mental health or psychiatric disorders; domestic violence, past history of ACS involvement, past history of trauma, other important information: Presenting Concerns: Check all that apply Physical abuse by referred parent Sexual abuse by referred parent Domestic violence by referred parent Substance abuse by referred parent Mental health issues of referred parent Cognitive limitations of referred parent Physical abuse by another parent Sexual abuse by another parent Domestic violence by another parent Substance abuse by another parent Mental health issues of another parent Cognitive limitations of another parent Relevant Current information on Biological Referred Parent(s): Is referred parent receiving any current service? If so please specify: Type, compliance, location, provider information other recommendations:

3 Child Information Name: DOB: / / Medicaid Number: Social Security Number: - - Child s Race/Ethnicity: Child s Dominant Language: English Spanish Other: Has child been referred to Early Intervention (for ages 0-3)? Yes No Was the child subsequently referred for Early Intervention services? Yes No Has the child been referred to the Committee on Preschool Special Education(3-5)? Yes No Are there any developmental or other special needs concerns? If child s primary caregiver is not referred parent, please check their relationship to the child: Biological Mother Kinship Foster Parent Legal Guardian Biological Father Non-Kinship Foster Parent When was child removed from Biological Parent(s): Reason for removal: Foster Parent's Name: Race/Ethnicity: Primary Caregiver s Dominant Language: English Spanish Other: Address of Primary Caregiver: Length of time in this foster home: Contact Numbers: or What is the structure of visitation? Previous foster placements (number of previous placements, child's age and length of time in each home, reason for removal from previous home): Permanency Plan for Child:

4 Stakeholder Information: Please include all information Parent s Attorney: Contact Numbers: Fax: Child s Attorney: Contact Numbers: Fax: ACS Attorney: Contact Numbers: Fax: ACS caseworker: Supervisor: Contact Numbers: Supervisor: Supervisor: Fax: Foster care agency caseworker: Supervisor: Foster care agency: Supervisor: Contact Numbers: Supervisor: Fax: Judge: Court Clerk: Contact Numbers: Fax:

5 Agency Consent Form Date: Caseworker s Name: Agency: Address: Telephone Number: Fax Number: Child s Name: D.O.B: Dear:, The above named child has been referred to the Infant Parent Project of the Early Childhood Center for parent-child intervention services. We are completing enrollment information before scheduling an intake and will need the written permission of the child s legal guardian. Please have the child s legal guardian or legally authorized authority sign and date the following statement and return this letter to us in the enclosed envelope as soon as possible. We will also need copies of the child s most recent physical examination. Please provide CIN Number. Permission for Child Therapy Services I hereby give permission to the Children s Evaluation to provide therapeutic services to. I understand that the intervention will be reviewed on a quarterly basis and progress toward goals will be monitored and available to the responsible foster agency. Signature of legal guardian Date Signature of Foster Care worker

6 Dear, The above named child was referred to the Infant-Parent Project of the Early Childhood Center for parent-child intervention services, and for assistance with behavior or developmental problems. The enclosed form must be completed and returned to us before we can begin to work with the child: 1. Permission by the legal guardian to provide therapeutic services. Please provide the following: 1. Copy of Medicaid/Insurance card 2. Copy of Immunization Record 3. Copy of most recent Physical Exam 4. Pediatrician information: Name, Address, Telephone Number or Clinic Information 5. Social Security numbers for child and parent We very much appreciate your time and attention to the information we are requesting, and look forward to working with you on behalf of this child. Sincerely, Anne Murphy, PhD Associate Professor of Clinical Pediatrics Director, Center for Babies, Toddlers and Families & The Early Childhood Center; Clinical Director, RFK Children's Evaluation