Dhs Evaluation Request Form Page 2
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2Does the child have any medical diagnoses? YES ___ NO ___
If yes, what? __________________________________________________________________________
Is the child on prescription medication/s for a medical disorder? YES ____ NO ____
Name of medications ___________________________________________________________________
Does the Child Have an IEP/504 Plan in school?
YES____ NO____
If yes, what is the IEP/504 for? ___________________________________________________________
What is the name of child’s school? _________________________________ Current Grade __________
How long has the child been in DHS care? (
Please provide a timeline summary of involvement)
Does the child have a history of documented physical abuse?
YES ___ NO ___
If yes, describe when and perpetrator ______________________________________________________
Does the child have a history of documented sexual abuse?
YES ___ NO ___
If yes, describe when and perpetrator ______________________________________________________
Has the child been formally examined for physical or sexual abuse?
YES ___ NO ___
If yes, when and by whom? ______________________________________________________________
Does child have visitation with biological parents, siblings, other relatives
? YES___ NO ___
If yes, how often? _____________________________
Supervised
Unsupervised?
Are there concerns related to any of the visitation? YES ___ NO ___
If yes, please describe __________________________________________________________________
What Is the Current Permanency Plan For the Child ? ______________________________
Do You Want a Parent/Child and/or Sibling Interaction?
YES ___ NO ___ How Many? _____
Please list participants for EACH requested interaction: ______________________________________
NOTE: More than two interactions will require additional office time.
Would You Like to Schedule a Feedback Session Following the Evaluation?
YES ___NO ___
If YES, by phone? _____________________ In office? ______________________________________
If YES, who will be in attendance in addition to the caseworker? ________________________________
Next Scheduled Court Hearing?
(date) _________________________________________________
Scheduling Constraints?
(please be specific) _____________________________________________
PERMISSION to verify appointment with Translink-RVTD/Medical Transport-NEMT (or similar
agency) if requested _________ (please initial)
CASEWORKER_______________________________ BRANCH_____________________
PHONE ________________________________ FAX ________________________________
I AGREE TO RECEIVE THE COMPLETED REPORT VIA EMAIL YES ___ NO ___
EMAIL: ___________________________________________________________________
Children’s Program – 7707 SW Capitol Hwy – Portland, OR 97219
Phone: (503) 452-8002 Fax: (503-452-0084
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