Form Dss-5225 - Request For Nc Kids Legal Risk Search - North Carolina Child Welfare Services
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2NC Kids – NC Division of Social Services, 820 S. Boylan Ave, 2445 Mail Service Center, Raleigh, NC 27699-2445
1-877-625-4371 (Toll-Free Office)
1-877-625-4374 (Toll-Free Fax)
REQUEST FOR NC KIDS LEGAL RISK SEARCH
Use this form to request an internal search for prospective families for a legal risk child. You will receive information on any families that
match the criteria completed below. Please submit a photo and profile that can be shared with potential families. Fax completed form to
NC Kids at 1-877-625-4374.
Child’s Name: _________________________________________________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~
(First)
(Middle)
(Last)
Race:
Am Indian/AK Native
Native Hawaiian/Pacific Islander
Ethnicity:_________________
Asian
White
Black/African
Other
Gender:
Male
Female
Date of Birth: ____________________
Status of Legal Risk:
Birth Parent 1:
Birth Parent 2:
Relinquished Rights (Date: _________ )
Relinquished Rights (Date: ___________)
TPR Granted (Date: __________ )
TPR Granted (Date: ___________)
TPR Filed
(Date: ___________)
TPR Filed
(Date: ___________)
Court has ceased reunification efforts
Court has ceased reunification efforts
TPR under appeal
TPR under appeal
If child also has Legal Parent, please note status of legal risk: ___________________________________
Parental Preference
Sibling Preference (check all that
apply):
(check all you will consider):
No Preference
No Preference
Two Parent Family
Female Siblings Only
Same Sex Female Couple
Male Siblings Only
Same Sex Male Couple
Must Be Oldest Child
Single Female
Must Be Only Child
Single Male
Other Children In Home
Must Be Youngest In Home
# of Siblings to be placed together: ____
Social Worker Contact Information:
(must include a legal risk search form for each)
Name: _____________________________
Sibling 1 Name: __________________________
Agency: ____________________________
Sibling 2 Name: __________________________
Address: ___________________________
Sibling 3 Name: __________________________
___________________________________
Sibling 4 Name: __________________________
Phone: _____________________________
Sibling 5 Name: __________________________
Fax: _______________________________
Sibling 6 Name: __________________________
Email: ______________________________
Director’s Signature: ____________________________
Worker’s Signature: _________________________
DSS-5225 (Rev. 11/2014)
Child Welfare Services
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