DHS-ORS-CIC-CPAR

New 03/05 Revised 08/29/05††††

 

24-HOUR DSPD COMMUNITY PLACEMENT ORS REFERRAL

*Please complete this form when the child is placed into 24-hour care and send it to the††

address below or fax it to 801-536-0378.††††††††††

CHILDíS INFORMATION

 

CHILDíS NAME: ___________________________________________ SS#: ______________________

 

DOB: __________________†††††† SEX:†† M___ F___†††† DATE OF ADMISSION: ___________________

 

CASE MGR NAME:__________________________________________PHONE: _________________

 

NAME OF PLACEMENT: _____________________________________PHONE:__________________

 

ADDRESS OF PLACEMENT: ____________________________________________________________

†††††††††††††††††††††††††††††††††††††††††††††††††††††

††††††††††††††††††††††††††††††††††††††††††††††††††††† ____________________________________________________________

 

†††††††††††††††††††† †††††††††††††††††††††††††††††††FATHERíS INFORMATION

 

FATHERíS NAME:_________________________________________SS#:________________________

 

DOB: _____________†† PHONE: __________________________

 

LAST KNOWN ADDRESS:_______________________________________________________________

 

LAST KNOWN EMPLOYER:________________________________PHONE:______________________

 

EMPLOYER ADDRESS: _________________________________________________________________

 

†††††††††††††††††††††††††††††††††††††††††† _________________________________________________________________

 

†††††††††††††††††††††††††††††††††††††††††††††††††† MOTHERíS INFORMATION

 

MOTHERíS NAME:_________________________________________SS#:________________________

 

DOB: ____________PHONE: _____________________________

 

LAST KNOWN ADDRESS:_______________________________________________________________

 

LAST KNOWN EMPLOYER: _________________________________PHONE: ____________________

 

EMPLOYER ADDRESS: _________________________________________________________________

††††††††††††††††††††††††††††††††

†††††††††††††††††††††††††††††††††††††††††† _________________________________________________________________

 

††††††††††††††††††††††††††††††††††† OFFICE OF RECOVERY SERVICES

†††††††††† ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††CIC TEAM 77

††††††††††††††††††††††††††††††††††††††††††††††††††††††† P.O. BOX 45011

†††††††††††††††††††††††††††††††††††† SALT LAKE CITY, UTAH84145-0011

†††††††††††††††††††††††††††††††††††††††††††† ††††††††FAX:801-536-0378†††

††††††††††††† FOR INFORMATION REGARDING PARENT ASSESSMENTS CONTACT ORS AT 536-8817