OCS and FINS Referral and Family Resource Center Intake Form
Office:
Worker:
Supervisor:
Email:
@dss.state.la.us
Email:
@dss.state.la.us
Work/Cell Phone:
W C
Work/Cell Phone:
W C
Case Name:
TIPS Number:
Attach program specific OCS Forms: 5, 10 (pages 1-5 thru last child’s page), 6, XI, CE-1, CE-2, 2A, Family Assessment and Case Plan OCS FRC-1
Revised: 08/09
Case/ Head of Household Information
Case Number (for FRC use only)
1. Referral Date
2. Referral Source
OCS FINS SELF
FS CPI AR HB/HA
3. Referral By:
SP/FC AD/FC ILP-YAP
Biological Adoptive
Foster Home Legal Guardian
4.
Head of Household
Family Type:
Relative
5. Family Size:
Yes No
6.
Court Involved::
Are services court ordered?
If yes, next court date:
7. SDM Rating:
LOW MODERATE
HIGH VERY HIGH
8. Case Plan Goal (check primary goal)
FS Prevent Placement Out of Home
FS Reunite Family
SP/FC Reunify with Parent or Caregiver
SP/FC Guardianship/Relative Custody
SP/FC Permanent Foster Care
AD/FC Adoption Placement
HB/HA Child Care Deficiency/CPI for Foster/Adoptive Home
Additional Case Information (including other services currently receiving;
domains of concern on Family Assessment; safety concerns):
Case Name / Head of Household
1.
Name (First, Last):
2/3.
Age / Sex:
4/5.
DOB / TIPS#:
6.7.
Race / Ethnicity:
Non-Hisp. Hisp. Unk.
8/9.
Marital Status/Participating:
Yes No
10.
Physical Address:
11.
City/State/ZIP
12.
Mailing Address:
13.
City/State/ZIP
14.
Parish:
1516.
Phone/Alternate Phone:
17.
Emergency Contact: Name/Phone:
18.
Education Level:
19.
Employer Name:
20.
Income: under $5,000 $5,000 to 12,000 $12,001 to 25,000
$25,001 to 50,000 $50,001 to 75,000 over $75,000
21.
TANF Eligible: YES NO
Services Requested:
Parenting Education
Visit Coaching
Family Skills Training
22.
Special Circumstances (check all that apply):
Mental Illness Violence Potential
Disability
Domestic Violence
Criminal Record Homicidal
Substance Use/Abuse Suicidal
Other:
Other Adult
Adult Household/Family Members/Other Adults
(18 years and older) who are part of case or are receiving services.
1.
Name (First, Last):
2/3/4.
Age/ Sex /Rel. to HH
5/6.
DOB/ TIPS
7/8.
Race / Ethnicity
Non-Hisp. Hisp. Unk.
9/10.
Marital Status/Participating:
Yes No
11.
Physical Address:
12.
City/State/ZIP
13.
Phone/Alternate Phone:
14/15.
Emergency Contact: Name/Phone:
16.
Educational Level
17.
Employer Name
18.
Income: under $5,000 $5,000 to 12,000 $12,001 to 25,000
$25,001 to 50,000 $50,001 to 75,000 over $75,000
19.
Services Requested:
Parenting Education
Visit Coaching
Family Skills Training
20.
Special Circumstances (check all that apply.):
Mental Illness Violence Potential
Disability
Domestic Violence
Criminal Record Homicidal
Substance Use/Abuse Suicidal
Other:
