Fillable York County Human Services CASSPChild & Adolescent Service (County of York)

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York County Human Services CASSPChild & Adolescent Service (County of York)

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The York County Human Services CASSPChild & Adolescent Service (County of York) form is 2 pages long and contains:

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  • 11 check-boxes
  • 76 other fields

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File type: PDF

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BROWSE COUNTY OF YORK (PA) FORMS

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York County Human Services
CASSPChild & Adolescent Service System Programming
100 W Market St, Suite B-129, York PA 17401
humanservices@yorkcountypa.gov
yorkcountyhumanservices.org
(717) 771-9095
Committed to the belief that family has the potential to energize hope, guide change, and foster healing
Child Name:
DOB:
MA Number (if applicable)
Home address:
Contact number:
School District: Grade:
Building:
Mental Health Diagnosis (if known):
IQ:
above 70
below 70 unknown
Parent/Guardian Information:
Name: Relationship:
Name: Relationship:
Phone/Email:
Phone/Email:
Primary language of student:
YES NO
Primary language of parent/guardian:
Is a translator able to be provided by school/organization?
Meeting availability:
Reason for referral (choose at least one):
Is mental health case management involved? YES NO
Agency (if known):
Does student have a current IEP? YES NO
School Attendance Service Coordination
Educational Placement More Services Needed
Behavior School Services Ineffective
Behavior Home Team Planning
Non-compliant Other:
Medical Issues
Please describe the behaviors or concerns which lead to making this CASSP referral:
Please list current services, if known:
What do you hope to accomplish through this CASSP meeting:
Person making referral:
Organization: Phone/Email:
version 2-21-2020
YORK COUNTY HUMAN SERVICES – FAMILY ENGAGEMENT UNIT
CHILD AND ADOLESCENT SERVICE SYSTEM PROGRAM (CASSP), FAMILY GROUP DECISION MAKING (FGDM),
FAMILY TEAM MEETING (FTM)
INFORMATION RELEASE AND CONSENT FORM
I hereby authorize York County Human Services Family Engagement Unit and the following organizations, with whom I am
currently working, to release and receive information. Please list all services that are currently in place (i.e. School, School
District, CYF, MH-IDD, SAM, JPO, Attorneys, Counseling Services, Etc.):
Professional’s Name
Agency
Phone
Email
from the record of
Name Birthdate
Street Address City State Zip
_
_____________________________________________ ______________________________________________
School District School
An
y or all of the following information may be exchanged for the purpose of referral/case coordination:
Psychiatric / Psychological reports
Vocational skills assessment
Teacher observations / School records
Social History / Family Information
Progress Reports
Attendance Data
Medical Reports
Report Cards
Neurological Reports
Admission / Discharge Reports
IQ test scores, aptitude and achievement tests
Behavior Reports
Human Services Department Information
This release is valid for 12 months from the date of signature and may be revoked by notifying a York CASSP Coordinator in writing or
witnessed verbally. I understand that treatment, payment, enrollment or eligibility for benefits and services is not subject to signing
this release. However, I choose to sign this release voluntarily to receive CASSP coordination services. I have read this form
carefully and understand what it means.
Signature of Minor (age 14 and above) Date
Signature of Parent or Guardian Relationship Date
Signature of Witness Date
*** Signature of Witness Date
Verbal release of information (***requires signature from two witnesses): This section is to be used for consumers who are unable to
provide a signature. We have witnessed that the consumer understands the nature of this release and has freely given his/her consent.
In accordance with Pennsylvania Regulations: “This information has been disclosed to you from records whose confidentiality is protected by State
Law. State regulations limit your right to make any further disclosure of this information without the prior written consent of the person to whom
it pertains.”
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York County Human Services CASSPChild & Adolescent Service (County of York)

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Completed 14 February 2021

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