DEPARTMENT OF FAMILY AND CHILDREN’S SERVICES

HOME SUPERVISION PROGRAM

DFCS Home Supervision Referral Form

Special Language need? / DFCS CASE NUMBER:
Home Supervision Court Ordered? Yes No
Supervised Visits Court Ordered? Yes No / Date Referred to HSP:
Informal Supervision? Yes No
REASON FOR REFERRAL:
Physical Abuse Sexual Abuse ______
Emotional Abuse Other (Please Explain) ______
Neglect ______
ALERTS/SPECIAL CIRCUMSTANCES: (Please include information such as: Pets, Mobile Home w/space number, apartment complex, Security gate, etc.)
No Contact By: ______Other: ______
Domestic Violence Confidentiality Issue ______
PARENT INFORMATION
/ DO NOT LIST CONFIDENTIAL ADDRESSES Please write CONFIDENTIAL if applicable
Mother’s Name: / DOB:
Address: / Phone #:
Father for: / Name: / DOB:
Address: / Phone #:
Father for: / Name: / DOB:
Address: / Phone #:
Father for: / Name: / DOB:
Address: / Phone #:

CHILD INFORMATION

/ DO NOT LIST CONFIDENTIAL ADDRESSES Please write CONFIDENTIAL if applicable
#1 / Child’s Name: / DOB: / Petition #:
Current Address:
School: / Phone #:
Released to: / Relationship: / Phone #:
Name & Relationship of all persons residing in the home:
More Children on Back Page /
Office Use Only
Date Received
Date Assigned
Assigned To
Date Closed

(Print form on green paper) Revised 08/29/01

DEPARTMENT OF FAMILY AND CHILDREN’S SERVICES

HOME SUPERVISION PROGRAM

#2 / Child’s Name: / DOB: / Petition #:
Current Address:
School: / Phone #:
Released to: / Relationship: / Phone #:
Name & Relationship of all persons residing in the home:
#3 / Child’s Name: / DOB: / Petition #:
Current Address:
School: / Phone #:
Released to: / Relationship: / Phone #:
Name & Relationship of all persons residing in the home:
#4 / Child’s Name: / DOB: / Petition #:
Current Address:
School: / Phone #:
Released to: / Relationship: / Phone #:
Name & Relationship of all persons residing in the home:
#5 / Child’s Name: / DOB: / Petition #:
Current Address:
School: / Phone #:
Released to: / Relationship: / Phone #:
Name & Relationship of all persons residing in the home:

DEPARTMENT OF FAMILY AND CHILDREN’S SERVICES

HOME SUPERVISION PROGRAM

RULES OF SUPERVISION

Court Ordered

Your child has been placed by the Court under the supervision of the Home Supervision Program pending a scheduled Court Hearing on ______, 20 _____ at ______

In Department ______. As a sign of good faith on your part, the Court requires that you live within the general and special rules of supervision, which are listed below. If you fail to abide by any of these rules, it may be necessary for the Court to return your child to Protective Custody, pending his/her Court Hearing.

GENERAL CONDIDITION

  1. Obey the laws of Federal, State and Local Government.
  2. Obey all lawful orders of the Court, Dependent Intake Social Worker and Home Supervision Social Worker.
  3. Notify the Dependent Intake Social Worker or Home Supervision Social Worker of any change of address within one day of change.
  4. Keep all appointments with the Dependent Intake Social Worker and Home Supervision Social Worker unless excused by proper authority.

CONDITIONS FOR HOME SUPERVISION SERVICES

Please Check:

Submit to chemical testing by: HSP Worker CAPS Other ______

Participate in counseling as directed by the Social Worker.

Home visits by HSP Social Worker: ______. (At HSP discretion? Yes No)

Number of visits per week

Supervised visits by HSP: ______. (At HSP discretion? Yes No)

Number of visits per week

Other: ______

______

______

These Rules of Supervision have been read and explained to me, and I agree to abide by them.

______

DEPENDENT INTAKE SOCIAL WORKER SIGNATURE OF PARENT/GUARDIAN

______

DEPENDENT INTAKE SOCIAL WORKER’S PHONE # WORKER # SIGNATURE OF CHILD (if appropriate)

______

Original: Home Supervision Social Worker DATE

Cc: Dependent Intake Social Worker

Parent/Guardian revised 08/29/01

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