Fillable Relative Caregiver Program Referral (State of Tennessee)

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Relative Caregiver Program Referral (State of Tennessee)

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U.S.A. forms for State of Tennessee

BROWSE STATE OF TENNESSEE (TN) FORMS

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Relative Caregiver Program
Referral
Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.
Distribution:
R
DA 2982
CS-1230, 01/20 Page 1
* Referral Source:
NAME
AGENCY
PHONE
E-MAIL
*Caregiver’s Name:
County:
*Caregiver’s Full Address:
*Caregiver’s Contact: (HOME)
(E-MAIL)
Is relative caregiver related to child(ren) by blood, marriage, or adoption? Yes No
Relationship is verified? Yes No
Child(ren) in legal custody of caregiver? Yes No OR informal custody of caregiver? Yes No
Household Income (if available): Weekly:
Monthly:
Yearly:
Does Birth Parent of child(ren) live in the same home as Relative Caregiver? Yes No
CHILDREN
DOB
RELATIONSHIP TO
CAREGIVER
SEX
RACE
SSN
RECEIVES SSI
(yes/no)
1.
2.
3.
4.
5.
Reason for referral: (Summarize family’s need for services)
Does family have any other agency involvement (DCS, TEIS, In-home provider, etc.)? Yes No
List other agency Case Manager assigned:
DHS Use/Optional for other agency
Caregiver is receiving Child Only Grant? Yes No
Families First? Yes Amount
No
SNAP ? Yes Amount
No
Department of Children’s Services
INSTRUCTIONS FOR USE OF FORM
CS-1230
Relative Care Program Referral
The Relative Caregiver Program is available for relatives to care for non-custodial children who require
out-of-home care. Through RCP, the children and relative caregivers receive supportive services and
family advocacy in order to prevent children from entering and/or re-entering state custody.
Case managers, court staff, DHS, private providers, and any other community member may use the RCP
referral form to refer a client to the program. Each referent will complete the form to the best of their
ability with any information that they have for the family. If some information is not known it may be
left blank unless there is an asterisk indicating that it is required.
The referent will then e-mail, fax, mail, or hand-in the referral to the respective provider for their region.
Once the referral is sent, DCS case managers and other private providers with access will upload the
form into TFACTS for record that the referral was made.
Once RCP receives the referral they will contact the referent about successful receipt, and contact with
the family.
Instructions for
CS-1230, 01/20
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Relative Caregiver Program Referral (State of Tennessee)

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Completed 12 April 2021

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