Face Sheet - Virginia Department Of Social Services
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APPENDIX “B
CASE TYPE
CPS-
______
Intake/Ongoing
FACE SHEET
Stabilization (
)____
Ongoing
For TDM Meeting
Foster Care____________
(Please check one )
Only fill out applicable info., for your case
NAME:______________________________________
DATE OF REFERRAL:__________________
DOB:__________________Age:__________________
CATEGORY:__________________________
SOCIAL WORKER:____________________________ MEDICAID #:__________________________
SOCIAL WORK SUPV:_________________________ DATE OF CUSTODY:___________________
GOAL:
RH
PWR
IL
Adoption
No. of PLACEMENTS (to date)___________
LEGAL BASIS FOR CUSTODY: (eg. Abuse/Neglect, etc.) _____________________________________
ZIP CODE UPON REMOVAL___________________
NATIONALITY/RACE:__________________
CHILD’S INFORMATION:
Current Placement Name
Group Home
TFC
Residential
Regular Foster Home
Other:______________________
Main Contact/Phone
Name_________________ Main Tel: _______________ Cell____________
If Child in Congregate Care,
give explanation (Why?)
Primary Caretaker(s) on Removal: _______________________ _________________ ______
______
Name
Relationship to Child Age
Race
_______________________ _________________ ______
______
Name
Relationship to Child Age
Race
Address:___________________________________________________________________Tel:____________
FAMILY INFORMATION:
Parents/Guardian’s Name
Address
Phone
Sibling(s) Name(s) & Current
Whereabouts
Grandparents Name(s)
Relative/Kin Name(s)
Updated by lucomdm-C:\Documents and Settings\mmn900\Desktop\Local Resources\TDM FACE Sheet - Richmond City Department of Social Services.doc (Rev. 1/09)
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