CPS Early Intervention Referral (CPS- EI/ECSE) 12/07 Cf 323
|[pic] |CPS Early Intervention Referral |
| |Child Protective Services (CPS) to |
| |Early Intervention/Early Childhood Special Education (EI/ECSE) |
Instructions: See OAR 413-015-0440(3) and 413-105-0080(1)
This form must be completed for any child under the age of 3 with a founded abuse disposition. If the child is age 3 up to kindergarten, a referral is recommended but not required. A copy of this form and the Oregon Department of Human Services (ODHS) Authorization for Release of Information (DHS 2099) (if obtained) must be sent to the EI/ECSE Program in the county where the child resides. Click here for a list of early intervention programs.
Early Intervention (Age 0 through 2)
Early Childhood Special Education (Age 3 up to kindergarten)
|Date the CPS assessment completed: | |Date of CPS Referral to EI/ECSE: | |
|1. Caseworker information |Phone: |( ) |
|Caseworker’s name: | |Fax: |( ) |
|Email address: | |
|Street address: | |
|City, state, ZIP code: | |
|2. Family information |
|Child’s name: | |
|Child’s gender: | M F O |Child’s age: | |Child’s date of birth: | |
|Child resides with: | |Relationship to child: | |
|Phone number: |( ) |Primary language: | |
|Address: | |
|City, state, ZIP code: | |
|3. Legal status (check one) |
| In parental custody, rights intact State jurisdiction, court-ordered guardian |
| Tribal jurisdiction, court-ordered guardian Other (please describe): | |
| Is there a no contact order? Yes No | |
| | |
|4. Medical, developmental or behavioral concerns |
| |a. Caseworker concerns (please list): | |
| |b. Parent concerns (please list): | |
| |c. Caregiver concerns (please list): | |
|5. Contact with family |
|Please provide helpful hints regarding contacting the family of residence, as well as any other appropriate information that may be useful in working with this |
|child and family. For example, provide information about the best time to call, alternate phone numbers, or if no phone is available, directions to the home, |
|preferences for time and place of screening etc. |
|6. Current services (Please check all that apply and list contact person and contact information.) |
| Babies First: | | CaCoon: | |
| Healthy Start: | | Oregon Health Plan: | |
| Early Head Start: | | Medical Provider: | |
|Other (please indicate program and contact information): |
Instructions for EI/ECSE: If child is age 0 through 2, please record as CAPTA referral. If child is age 3 up to kindergarten, please record as DHS referral. Send status of referral/feedback to caseworker listed above.
You can get this document in other languages, large print, braille or a format you prefer. Contact the Child Welfare Director’s Office at 503-945-5600 or email ChildWelfare.DirectorsOffice@dhsoha.state.or.us. We accept all relay calls or you can dial 711.
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