"*" indicates required fields Date Placement Is Needed* CHS Specialist Name*CHS Specialist Best Contact Phone*(###) ###-####County of Custody*Type of Referral* Respite Adoptive Not Listed Select AllChild Name* First Last Ethnicity*Gender*Date of Birth* Are There Additional Children?* Yes No Child #2 Name First Last Child #2 RaceChild #2 GenderChild #2 Date of Birth Child #3 Name First Last Child #3 RaceChild #3 GenderChild #3 Date of Birth Additional DetailsNeeds of Child / Children*Child Strengths*Any upcoming visits or appointments for children?*Important Notes / Comments*If this is a disruption, please include what is causing the disruption, if you have exhausted all options are you team already, and if DSS currently knows).When is Placement Needed?Optional InformationCounty of CustodyReferring Social Worker Email Child's Current SchoolGrade LevelKindergartenFirst GradeSecond GradeThird GradeFourth GradeFifth GradeSixth GradeSeventh GradeEighth GradeNinth GradeTenth GradeEleventh GradeTwelfth GradeOther / NALevel of Care NeededBehaviors and/or DiagnosesAllergiesMedicationsTherapy Information
