Child Protective Services (CPS) to
Early Intervention/Early Childhood Special Education (EI/ECSE)
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See Policy: I-E-8 & I-AB.4
CF 323 (12/07)
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Instructions: This form must be completed for any child, under the age of 3, with a founded abuse disposition. If child is age 3 up to kindergarten, referral is recommended but not required. A copy of this form and the Department of Human Services (DHS) Authorization for Release of Information (DHS 2099) (if obtained) is sent to the EI/ECSE Program in the county where the child resides. For a list of programs see
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(http://www.oregon.gov/DHS/children/committees/capta/capta.shtml), Early Intervention Referrals.
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Early Intervention (Age 0 through 2) Early Childhood Special Education (Age 3 up to kindergarten)
Founded Date: / 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 / 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.
CF 323 (12/07)
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