Appendix L - CSEC Referral Form for Georgia Cares Georgia Cares Referral Form Division of Family and Children Services Fax to: 404-371-1030 or Email to: referrals@georgiacareconnection.com Client’s Information Youth Name: Social Security Number: Date of Birth: Gender: Is client pregnant? ☐ Yes ☐ No Is client actively parenting? ☐ Yes ☐ No Ethnicity: Language Spoken: Does youth have a disability? Who has custody of youth? Parents Father Mother DFCS DJJ Other: ☐ ☐ ☐ ☐ ☐ ☐ If in the custody of DFCS or DJJ, when did custody begin? Client’s Address Legal address: County: Is this youth’s current address? Yes No Is this a safe location? Yes No ☐ ☐ ☐ ☐ Current address (if different): County: Is this a safe location? Yes No ☐ ☐ Contact: Name of legal guardian: Phone number: If youth does not reside with legal guardian, provide the phone number for current placement: Medicaid /CMO ID: Insurance: Please check all that applies: DJJ Committed Trespassing of Law Enforcement (Detained by Law Enforcement) ☐ ☐Criminal ☐Custody ☐DFCS Involvement (Foster Care) Involvement (Home) Use Runner (Running 3 or more ☐DFCS ☐Firearm/Weapon ☐Frequent times in the past 6 months) Involvement Giving False Name for Solicitation ☐Gang ☐ ☐Homeless ☐Loitering ☐On Probation (DJJ or Court) ☐ Police Report ☐Runaway/Unruly Petition ☐Sexual Abuse ☐Sexual Exploitation Abuse of Probation ☐Shoplifting ☐Substance ☐Truancy/Suspension ☐Violation DFCS Referral Information Name of Referral Source: Job Title:
Appendix L - CSEC Referral Form for Georgia Cares Georgia Cares Referral Form Division of Family and Children Services Fax to: 404-371-1030 or Email to: referrals@georgiacareconnection.com Client’s Information Youth Name: Social Security Number: Date of Birth: Gender: Is client pregnant? ☐ Yes ☐ No Is client actively parenting? ☐ Yes ☐ No Ethnicity: Language Spoken: Does youth have a disability? Who has custody of youth? ☐ Parents ☐ Father ☐ Mother ☐ DFCS ☐ DJJ ☐ Other: If in the custody of DFCS or DJJ, when did custody begin? Client’s Address Legal address: County: Is this youth’s current address? ☐ Yes ☐ No Is this a safe location? ☐ Yes ☐ No Current address (if different): County: Is this a safe location? ☐ Yes ☐ No Contact: Name of legal guardian: Phone number: If youth does not reside with legal guardian, provide the phone number for current placement: Medicaid /CMO ID: Insurance: Please check all that applies: ☐ DJJ Committed ☐Criminal Trespassing ☐Custody of Law Enforcement (Detained by Law Enforcement) ☐DFCS Involvement (Foster Care) ☐DFCS Involvement (Home) ☐Firearm/Weapon Use ☐Frequent Runner (Running 3 or more times in the past 6 months) ☐Gang Involvement ☐ Giving False Name ☐Homeless ☐Loitering for Solicitation ☐On Probation (DJJ or Court) ☐ Police Report ☐Runaway/Unruly Petition ☐Sexual Abuse ☐Sexual Exploitation ☐Shoplifting ☐Substance Abuse ☐Truancy/Suspension ☐Violation of Probation DFCS Referral Information Name of Referral Source: Job Title:
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