Case Name: - Riverside County Dept. of Public Social Services



|CWS/CMS Child/NMD Case #:       |J#:       |Date of Assessment:       |

|Child’s/NMD’s Name:       |DOB:       |

|Case Social Worker’s Name:       |CSW Telephone:       |

|CPU/SCI Social Worker’s Name:       |CPU/SCI SW Telephone:       |

|Qualifying Condition(s): |

|Medical/Physical |

|Describe all the medical or physical problems that place this child or non-minor dependent (NMD) at a higher risk. |

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|Mental Health/Psychological |

|Describe all the mental health problems that place this child or NMD at a higher risk. |

|___________________________________________________________________________________________________________________ |

|___________________________________________________________________________________________________________________ |

|___________________________________________________________________________________________________________________ |

|___________________________________________________________________________________________________________________ |

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|Behavioral |

|Describe all the behavioral concerns that place this child or NMD at a higher risk. |

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|___________________________________________________________________________________________________________________ |

|___________________________________________________________________________________________________________________ |

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|___________________________________________________________________________________________________________________ |

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|Verification: Must have two or more sources of verification. Attach any documentation supporting a special care increment. Example: letters from school,|

|doctors, other professionals or resources. |

|Name |Agency |Relationship to Child/NMD |Phone (w/area code) |

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|Date received by the CPU/SCI Unit: |

Note: Attach an additional page, if more space is needed. When completed, please return this document and all supporting documentation to:

Riverside County Department of Public Social Services, ATTN: Placement/SCI Unit

10281 Kidd St., 2nd Floor

Riverside, CA. 92503

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