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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