Dhs Evaluation Request Form
Download a blank fillable Dhs Evaluation Request Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dhs Evaluation Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2DHS EVALUATION REQUEST
Please complete this form so we may review the information to determine if we can help you. Return
the completed form to the Children’s Program and you will be contacted with a date and time for the
evaluation.
Name of Person to Be Evaluated
______________________________________________________
Client Recipient ID# ________________Age/DOB _________________________Gender____________
Client’s Primary Language ______________________________________________________________
Names/Ages of Family Members
Biological Mother __________________________________________________ Age ____________
Biological Father ___________________________________________________ Age ____________
Siblings __________________________________________________________ Age ____________
Significant Other ___________________________________________________ Age ____________
With Whom Does The Child Live?
Foster parent/caregiver name(s) __________________________________________________________
Phone/Contact numbers ________________________________________________________________
How long has the child been with current caregivers? _________________________________________
Is the child in DHS custody? YES____ NO____ If no, in whose custody?________________
What SPECIFIC concerns do you currently have regarding the child?
What SPECIFIC Questions Do You Want Addressed In the Present Evaluation?
____Current Functioning (intellectual, emotional, academic, developmental)
____Treatment or Special Services Needed
____Diagnosis
____Ability to Parent
____Strength/Bond of Relationship Between _________________________________________
____Long-term Placement Needs
____Ability to Transition to a Permanent Home
____Placement Considerations (e.g., residential treatment)
Other Questions Not Addressed (please be specific): __________________________________________
Will Foster Parent/Caregiver Attend the Evaluation?
YES ___ NO ___
Who Will Transport the Child?
______________________________________________________
May We Make an Appointment Reminder Call?
YES ___ NO ___
Previous Evaluation/Testing?
YES ____ NO ____
When? ________________________ Where? ______________________________________________
What (if any) was the child’s most recent psychological diagnosis? ______________________________
Is the child currently in counseling? YES ____ NO ____ If so, where and for how long?_____________
____________________________________________________________________________________
Is the child on prescription medication/s for a mental disorder? YES ____ NO ____
Name of medications ___________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal