Families In Need Of Services (Fins) Office Referral/screening Form printable pdf download

JUDICIAL DISTRICT COURT, PLAQUEMINES PARISH

DEPT. OF YOUTH & FAMILY SERVICES

FAMILIES IN NEED OF SERVICES (FINS) OFFICE

REFERRAL/SCREENING FORM

Hand Deliver/Mail To: 301 Main Street, Rm. 230, Belle Chasse, LA. 70037

Fax. To: 504 393-5760, Telephone: 504 393-5765

Date_______________________

School/Grade:____________________________

State of Louisiana in the interest of:

CHILD’S NAME:_______________________________DOB______Age_____Gender_______Ethnicity_______ SS#____-___-_______

Current Interventions: 504______ Special Education______ IEP____ FBA______ IBP______ Tier Intervention Level_______

Mental Health Diagnosis _____________________________________________________Medications______________________

Biological Mother or

LEGAL GUARDIAN:________________________________________DOB________Age_____SS#____-___-_______

Last

First

Middle

Address:_______________________________________________Phone: Home_____________________

Employer:_____________________________________________

Cell/Work_____________________

Biological Father or

LEGAL GUARDIAN:________________________________________DOB________Age_____SS#____-____-_______

Last

First

Middle

Address:____________________________________________________Phone: Home_____________________

Employer:__________________________________________________

Cell/Work_____________________

Parents’ Marital Status: ____Married____Divorced_____ Separated_____Never Married

Others In The Home:

Name

Age

DOB

Gender

Social Security No.

_______________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Louisiana Children’s Code Art. 730. Grounds

Allegations that a family is in need of services must assert one or more of the following grounds:

_______(1) That a child is truant or has willfully and repeatedly violated lawful school rules. Frequency of Absences:________________

Explain:_________________________________________________________________________________________________

______________________________________________________________________________________________________

_______(2) That a child is ungovernable.

Explain:________________________________________________________________________________________________

_______(3) That a child is a runaway. Frequency:______________________________________________________________________

_______(4) That a child has repeatedly possessed or consumed intoxicating beverages, or that he has misrepresented or deceived his age

for the purpose of purchasing or receiving such beverages from any person, or has repeatedly loitered around any place where

such beverages are the principal commodities sold or handled. Explain:_______________________________________________

_______(5) That a child has committed an offense applicable only to children; such as, gambling, purchase or use of alcohol, cigarettes,

etc. Explain:_____________________________________________________________________________________________

_______(6) That a child under ten years of age has committed any act which if committed by an adult would be a crime under any federal,

state, or local law. Specify Crime:____________________________________________________________________________

_______(7) That a caretaker has caused, encouraged, or contributed to the child's behaviors enumerated in this Article or to the

commission of delinquent acts as defined in Title VIII.

Explain:_________________________________________________________________________________________________

_______(8) That, after notice, a caretaker has willfully failed to attend a meeting with the child's teacher, school principal, or other

appropriate school employee to discuss the child's truancy, the child's repeated violation of school rules, or other serious

educational problems of the child. Explain:_____________________________________________________________________

_______(9) That a child has been found incompetent to proceed with a delinquency matter under Article 832 et seq.

_______(10) That a child is found in possession of a handgun or semiautomatic handgun under circumstances that reasonably tend to

exclude any lawful purpose. Explain:__________________________________________________________________________

_______(11) Child found to be engaged in Cyber Bullying

Written Basis For

Complaint/Referral:______________________________________________________________________________________________

_______________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Other Child-Serving Agencies - involved with Child and/or

Family:________________________________________________________________________________________________________

Certification:

I certify that the allegations above are true and correct upon my information and belief in regard to the above named child and family is a Family In Need Of Services

according to Louisiana Children’s Code.

Referred By (Print):_____________________________________________ Title:__________________________________

Signature:_____________________________________________________ Telephone:_____________________________

(rev 01/03/12)

Families In Need Of Services (Fins) Office Referral/screening Form

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