Tennessee



|[pic] |Tennessee Department of Children’s Services |

| |Termination of Parental Rights Referral |

1. Contact the local Child Support Enforcement Office. Tell them who you are and that you need to know a) whether support has been established on the parent for each child, and b) whether any payments have been made. Ask them nicely to fax you any orders setting support, orders holding a parent in contempt, and a payment history for each parent. Have the children’s names and dates of birth and the parents’ names and social security numbers handy as they usually request that information. Ask them for the TCSES (Tennessee Child Support Enforcement Services) number for each parent’s case.

2. Contact the jails in each county where you think the parent may have been incarcerated. Ask the jail administrator to fax you a print-out of the parent’s dates of incarceration (as far back as they can go is best, but make sure it at least covers the time the child has been alive.) Some counties are now asking for a letter on letterhead to be faxed to them first, so be prepared to put that request in writing if needed.

3. If the parent has a criminal history, go to the circuit or criminal court clerk’s office in each county where you know they have had legal charges and ask for a certified copy of their criminal convictions (not just a history of their charges and dispositions). Make sure you have the parent’s full name, date of birth, and social security number on hand. Make sure the clerk is giving you their convictions out of both general sessions and criminal courts.

4. Study the complete file on the family.  Read case recordings for all case managers assigned to the case.  Read service provider records.  Gather any missing service provider records.  Make notes or tab significant information.  If there have been previous removals of the children from the parents, gather those old files and review them.  The fact that you have recently been assigned to the case will not be accepted as an excuse for not knowing the case and not being able to provide the necessary information to the DCS attorney to draft the TPR petition.  Do not submit this request if you have not gone through the entire file.

|      |      |      |requests that legal review and |

FSW Name FSW Office Phone FSW Cell Phone

|accept this referral to draft a TPR petition on the following case. The commitment county is |      |. |

I have attached the required documents (see checklist on last page).

PARENT INFORMATION

Include all parents, including legal, presumptive legal, biological, and putative/alleged parents.

MOTHER

List mother’s full name, including maiden name, date of birth and verified address.

*If address isn’t verified please provide last known address. If unable to locate, attach affidavit of diligent search.

|      | |      | |      |

|Mother’s Full Name | |DOB | |Address |

List children’s full names (as listed on the children’s birth certificates) and dates of birth. Check to verify that long form birth certificate(s) are attached

|      | |      |

|Child Name | |DOB |

|      | |      |

|Child Name | |DOB |

|      | |      |

|Child Name | |DOB |

|      | |      |

FATHER 1

List father’s full name, date of birth and verified address.

*If address isn’t verified please provide last known address. If unable to locate, provide affidavit of diligent search.

|      | |      | |      |

|Father’s Full Name | |DOB | |Address |

List children’s full names (as listed on the children’s birth certificates) and dates of birth. Check to verify that long form birth certificate(s) are attached.

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

FATHER 2

List father’s full name, date of birth and verified address.

*If address isn’t verified please provide last known address. If unable to locate, provide affidavit of diligent search.

|      | |      | |      |

|Father’s Full Name | |DOB | |Address |

List children’s full names (as listed on the children’s birth certificates) and dates of birth. Check to verify that long form birth certificate(s) attached

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

FATHER 3

List father’s full name, date of birth and verified address.

*If address isn’t verified please provide last known address. If unable to locate, provide affidavit of diligent search.

|      | |      | |      |

|Father’s Full Name | |DOB | |Address |

List children’s full names (as listed on the children’s birth certificates) and dates of birth. Check to verify that long form birth certificate(s) attached

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

|Child Name | |DOB | |

|      | |      | Biological Putative Legal |

* If there are additional parents, please list them on an additional sheet of paper.

List date(s) of marriage (for all parents) and complete with name(s) of spouse(s)

|      | |      | |      |

|Parent’s Name | |Date of Marriage | |Name of Spouse |

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|Parent’s Name | |Date of Marriage | |Name of Spouse |

|      | |      | |      |

|Parent’s Name | |Date of Marriage | |Name of Spouse |

List date(s) of divorce (for all parents) complete with name(s) of former spouse(s).

|      | |      | |      |

|Parent’s Name | |Date of Divorce | |Name of Spouse |

|      | |      | |      |

|Parent’s Name | |Date of Divorce | |Name of Spouse |

|      | |      | |      |

|Parent’s Name | |Date of Divorce | |Name of Spouse |

Has any parent surrendered, had his/her rights terminated, died, or signed a waiver or denial of paternity? If so, which parent and dates (attach copies of any surrender, termination, death certificate, or waiver/denial):

|      | |      | |      |

|Parent’s Name | |Type (Surrender/TPR/etc.) | |Name of Spouse |

|      | |      | |      |

|Parent’s Name | |Type (Surrender/TPR/etc.) | |Name of Spouse |

|      | |      | |      |

|Parent’s Name | |Type (Surrender/TPR/etc.) | |Name of Spouse |

CUSTODY INFORMATION

|Date child(ren) entered custody: |      | |

|Date of adjudication: |      |

|Date(s) of all previous custody episode(s): |      |

|Brief summary of allegations that brought the child(ren) into custody: |      |

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DATES OF PERM PLANS

|Date of Plan: |      |Date of Ratification: |      |Goal(s): |      |

|Date of Plan: |      |Date of Ratification: |      |Goal(s): |      |

|Date of Plan: |      |Date of Ratification: |      |Goal(s): |      |

|Date of Plan: |      |Date of Ratification: |      |Goal(s): |      |

|Date of Plan: |      |Date of Ratification: |      |Goal(s): |      |

|Date of Plan: |      |Date of Ratification: |      |Goal(s): |      |

DATES FOR CRITERIA AND PROCEDURES FOR TPR

|Dates Criteria were signed by mother: |      |

If mother did not sign criteria, did we provide or attempt to provide a copy of the Criteria to the mother? If so, how?

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|Dates Criteria were signed by father (Name): |      |

If father did not sign criteria, did we provide or attempt to provide a copy of the Criteria to the father? If so, how?

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|Dates Criteria were signed by father (Name): |      |

If father did not sign criteria, did we provide or attempt to provide a copy of the Criteria to the father? If so, how?

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|Dates Criteria were reviewed by the Court with mother: |      |

|Dates Criteria were reviewed by the Court with father (Name): |      |

|Dates Criteria were reviewed by the Court with father (Name): |      |

DATES OF INCARCERATIONS

We need to know ALL DATES, PLACES AND REASONS FOR INCARCERATION FOR ALL PARENTS since the child(ren) entered custody. Please attach additional sheets as necessary to make sure that all incarcerations are listed.

|      | |      | |      |

|Parent’s Name | |Date of last visit | |Dates of all visits in the last four months |

|      | |      | |      |

|Parent’s Name | |Date of last visit | |Dates of all visits in the last four months |

Failure to Pay Child Support (This ground applies when a parent has failed to pay child support for the child(ren) in the four months before the petition is filed or has only provided token support. Do not use this ground if the parent has been incarcerated at any time during the four months before the petition is filed.)

|      |

|Parent’s Name |

|Date parent ordered to pay child support: |      |Amount parent ordered to pay: |      |

|Was this a child support order or a permanency plan ratification: |      |

|Total amount parent has paid in the last four months: |      |Date of last payment: |      |

TCSES screen attached (if applicable)

Copy of Child Support Order (if applicable)

|      |

|Parent’s Name |

|Date parent ordered to pay child support: |      |Amount parent ordered to pay: |      |

|Was this a child support order or a permanency plan ratification: |      |

|Total amount parent has paid in the last four months: |      |Date of last payment: |      |

TCSES screen attached (if applicable)

Copy of Child Support Order (if applicable)

Failure to Establish Suitable Home in the First Four Months (This ground applies when, for the four

month period of time following the removal of the child from the home or custody of a parent, the parent

failed to make reasonable efforts to provide a suitable home for the child and demonstrated a lack of

concern for the child such that it appears unlikely the parent will be able to provide a home for the child at

an early date. DCS must make reasonable efforts to assist the parent during this four-month period of

time. NOTE that a suitable home can mean more than just the physical home environment).

Mother Father Both (if both, include information for each parent separately)

|Date removed from parent: |      | |

What did parent do to try to provide a suitable home in the first four months after removal?

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Have they done anything since that time?

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What reasonable efforts did DCS provide to assist them in the four months after removal?

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What prevents the child from being returned to the home?

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INCARCERATED PARENT (This ground applies when the parent was incarcerated all or some of the four months before the petition is filed, and if the parent failed visit in the four months prior to incarceration; failed to pay support in the four months prior to incarceration; or engaged in conduct that demonstrated a wanton disregard for the welfare of the child at any time. Do not use this ground if the parent was not incarcerated all or part of the four months before the petition is filed)

| |      |is currently incarcerated or was |

incarcerated in the four months preceeding the filing

Mother Father Both (if both, include information for each parent separately)

SENTENCE INFO (LENGTH OF TIME AND CONVICTION):

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In the four months BEFORE parent went to jail, did the parent fail to visit or fail to support (or both) the child? Yes No

|Date of last visit: |      |

|Date and amount of last support payment: |      |

|If failure to support, include child support order info: |      |

Did parent exhibit a wanton disregard for the welfare of the child? Yes No

Explain:

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SUBSTANTIAL NON-COMPLIANCE WITH PERMANENCY PLAN (This ground applies when the parent has not substantially complied with the responsibilities of the permanency plan.)

Mother Father Both (if both, include information for each parent separately)

What has parent completed/complied with:

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What has parent not completed/complied with:

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What has DCS done to assist the parent with completing/complying with the plan:

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Has the court previously found the parent to be in substantial noncompliance? If so, when and why:

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Perm Plan(s) attached

PERSISTENCE OF CONDITIONS (This ground applies when the child has been removed from the home or custody of the parent for at least six months, and the reasons that the child was removed still exist or other reasons exist that would result in further abuse or neglect of the child if the child was returned to the parent. Do not use this ground if the child has not been removed longer than six months).

Mother Father Both (if both, include information for each parent separately)

|Has the child been removed from the home or custody of the parent for more than six months: | Yes No |

Why was the child removed from the home or custody of the parent:

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|Do these conditions still exist? | Yes No |

|Are there other reasons why the child cannot return to the home or custody of the parent? | Yes No |

If so, what are they?

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SEVERE CHILD ABUSE (This ground applies when the parent has committed severe child abuse against any child)

| |      |has/have committed severe child abuse against |

|      | |

|The conduct that constitutes severe abuse was: |      |

|Explain: |

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Attach any orders adjudicating severe abuse if applicable

SENTENCED TO MORE THAN TWO YEARS IMPRISONMENT FOR CHILD ABUSE (This ground applies when the parent has been sentenced for more than two years imprisonment for child abuse or sex trafficking of children).

| |      |has/have been sentenced to more than two years |

|imprisonment for child abuse against |      |. |

Criminal conviction attached

|Criminal offense and date: |      |

| |      |has/have been convicted for trafficking for |

commercial sex act under § 39-13-309 or a sex trafficking of children offense under the laws of another

state that is substantially similar. 

Criminal conviction attached

|Criminal offense and date: |      |

TEN YEAR SENTENCE WHEN CHILD IS LESS THAN EIGHT YEARS OLD (This ground applies when a parent has received a consecutive sentence of ten or more years and the child was under 8 at the time the sentence was entered by the Court. This ground can still be applicable if there are multiple sentences that add up to at least ten years).

| |      |has/have been sentenced as a result of a criminal |

|act, under a sentence of ten (10) or more years and the child(ren) |      |

was/were under eight (8) years of age at the time the sentence was entered by the Court.

Criminal conviction attached

|Convicted offense and date: |      |

WRONGFUL DEATH OF OTHER PARENT (This ground applies when the parent has been convicted or found civilly liable for the wrongful death of the other parent).

| |      |has been convicted of or found civilly liable for the |

|intentional and wrongful death of the child(ren)’s |      |other parent |

or legal guardian.

Criminal conviction or civil order attached

INCOMPETENCE (This ground applies when the parent is incompetent to adequately provide for the care and supervision of the child due to the parent’s impaired mental condition).

| |      |Is/are incompetent to adequately provide for the |

further care and supervision of the child(ren) because their mental condition is presently so impaired and is so likely to remain so that it would be unlikely that they will be able to assume or resume the care of and responsibility for the child(ren) in the near future.

Psychological or Psychiatric Evaluations showing incompetency to parent attached OR explain why parent is incompetent to parent:

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PUTATIVE FATHER’S FAILURE TO ESTABLISH PARENTAGE (Only check which ones apply)

THIS GROUND DOES NOT APPLY TO ANY MAN WHO:

1. Was married to the child’s biological mother at the time of the child’s birth or 300 days before the child’s birth,

2. attempted to marry the child’s biological mother,

3. has been adjudicated by a court to be the father of the child,

4. has signed a voluntary acknowledgement of paternity,

5. has adopted the child, or

6. is listed on the birth certificate.

|How and when did putative father |      |get notice of alleged paternity? |

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| |      |has failed without good cause or excuse, to make |

reasonable and consistent payments for the support of the child(ren) in accordance with the child support.

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|Explain: |

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| |      |has failed to seek reasonable visitation with the |

child(ren), and if visitation has been granted, has failed to visit altogether, or has engaged in only token

visitation.

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|Explain: |

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| |      |has failed to manifest an ability and willingness to |

assume legal and physical custody of the child.

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|Explain: |

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| |Placing the child in the custody of |      |would pose a risk of |

substantial harm to the physical or psychological welfare of the child(ren).

|Explain: |

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| |      |has failed to file a petition to legitimate the child(ren) |

within thirty (30) days after notice of alleged paternity or after the father(s) made a claim of paternity.

INABILITY AND UNWILLINGNESS TO ASSUME CUSTODY (This ground applies when a parent has failed to demonstrate an ability and willingness to assume custody of the child and placing the child in the parent’s custody would pose a substantial risk of harm to the child).

| |      |has failed to manifest, by act or omission, an ability |

and willingness to personally assume legal and physical custody or financial responsibility of the child(ren);

|Explain why: |

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AND,

| | | |

| |Placing the child(ren) in the legal and physical custody of |      |

pose a risk of substantial harm to the physical or psychological welfare of the child(ren).

|Explain why: |

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BEST INTERESTS

This section must be completed on every referral. Best interest factors include the effect a termination will have on the child’s need for stability and continuity of placement; effect a change of caretakers and physical environment will likely have on the child; whether the parent has demonstrated continuity and stability; whether the parent has a healthy attachment with the child; whether the parent has maintained regular visitation or contact; whether the child is fearful of living in the parent’s home; whether the parent or individuals in the parent’s home trigger or exacerbate the child’s trauma; whether the child has healthy parental attachments with someone other than the parent; whether the child has significant relationships with other persons (caregivers, biological siblings, foster siblings, etc.); whether the parent has demonstrated a lasting change of circumstances; whether there is criminal activity in the parent’s home or by the parent; whether there is use of alcohol or other substances that render parent consistently unable to care for the child; whether parent has taken advantage of services; whether the Department has made reasonable efforts to assist the parent; whether parent has demonstrated a sense of urgency in establishing paternity or seeking custody of the child; whether the parent or other person in the home has abused this child or any child or adult; whether the parent has ever provided stable care for this or any child; whether the parent has maintained a home that meets the child’s needs; whether the physical environment of the parent’s home is healthy and safe; whether the parent has consistently provided more than token child support; and whether the parent’s mental or emotional fitness would be detrimental to the child.

Please provide detailed information about why termination would be in the child’s best interests. Include information for each child, including information about the child’s placement and potential for adoption (e.g., where the child is placed; how long the child has been placed there; whether the child wishes to be adopted; whether the placement is interested in adopting).

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I have reviewed this document and agree the case is ready for TPR and the FSW has all the information and documentation necessary to meet with legal to draft the TPR Petition. I have reviewed this request to Draft TPR and believe it is adequately completed and I have confirmed that the following documents are attached to this request if applicable to this case. The following documents, if applicable to the facts of your case, are required to be attached to this request, unless your regional legal has instructed otherwise.

| |All children’s LONG FORM birth certificates (Do not submit this request if you only have the short form birth certificate.) |

| |Surrenders |

| |DNA test results |

| |Parental death certificates |

| |Putative father Waiver of Interest |

| |Legal father’s Denial of Paternity |

| |Divorce Decree |

| |All Permanency Plans (finalized, signed, or ratified) |

| |Timeline of Reasonable Efforts that is chronological, detailed and date specific |

| |All signed Criteria and Procedure for Termination of Parental Rights |

| |Affidavit of Presentation whenever parent does not sign Criteria |

| |Certified Criminal Convictions for each parent |

| |Psychological evaluation showing parent is incompetent to parent child |

| |Certified Child Support or Parentage Orders (if any exist) |

| |Affidavit of Diligent Search for any absent parent |

|Case Manager’s Signature | |Date |

|Team Leader/Coordinator’s Signature | |Date |

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