CHINS INTAKE FORM

  • Posted on: 7 August 2020
  • By: Juvenile Court ...
 
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FULTON COUNTY JUVENILE COURT
CHINS INTAKE FORM
Parent / Guardian Contact Information
(If Unemployed, Leave Blank)
(If None, Leave Blank)
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(If None, Type N/A or Leave Blank
(If None, Type NA or Leave Blank)
(If None, Type NA or Leave Blank)
PEOPLE LIVING IN THE HOME
CHILD'S HEALTH AND SCHOOL INFORMATION
(For the 2020-2021 School Year)
(If No Health Insurance, Type NONE)
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(check all that apply)
Confidentiality and Disclosure Notices:
Confidentiality and Disclosure of Client The Behavioral Health Unit of FCJC is a collective body with members representing court employees and other vetted external agencies including (but not limited to) Georgia Health Partners, Progress Place and Chris 180. The CHINS Unit may make referrals to the Behavioral Health Unit and also to outside agencies, community organizations and/or consulting mental health professionals as necessary.
As Mandatory Reporters, the law authorizes us to disclose confidential information in certain circumstances without the consent of the client or client's authorized representative. These circumstances without the consent of the client or client's authorized representative. These circumstances include cases in which an individual is deemed a danger to self or others or if there is suspected abuse and/or neglect.
ELECTRONIC SIGNATURE AGREEMENT
By selecting the "I Accept" button, you are signing this Application electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Application. By selecting "I Accept" using any device, means or actions agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing.