Email Address: Case Supervisor Name and Number: Name of Case Worker (If different from referral source): Contact information of Case Worker: DFCS Information Is this youth in DFCS custody? Yes No ☐ ☐ What is the status of the case?☐ Investigative Support ☐Family ☐Placement What is the overall placement history? Date of upcoming Family Team Meeting (if applicable): Date of the next court hearing: What is the purpose of this court hearing? List the services that are currently in place: Describe reason for referral to Georgia Cares: Please attach the following documents: Release of Information (Required) ☐ Psychological Evaluation ☐ Other applicable documents ☐
Email Address: Case Supervisor Name and Number: Name of Case Worker (If different from referral source): Contact information of Case Worker: DFCS Information Is this youth in DFCS custody? ☐ Yes ☐ No What is the status of the case?☐ Investigative ☐Family Support ☐Placement What is the overall placement history? Date of upcoming Family Team Meeting (if applicable): Date of the next court hearing: What is the purpose of this court hearing? List the services that are currently in place: Describe reason for referral to Georgia Cares: Please attach the following documents: ☐ Release of Information (Required) ☐ Psychological Evaluation ☐ Other applicable documents
2015%20Statewide%20Model%20Protocol.docx