C.H.I.N.S Referral Form - Fulton County Juvenile Court

CHINS Referral Form

Acknowledgements and Child Information

Detention Disclaimer: Effective January 1, 2014, children who may be determined to be ungovernable and/or truant are now referred to as Children in Need of Services (CHINS). OCGA 15-11-415(b) also states that a Child in Need of Service CANNOT be detained as a means of punishment and/or avoidance of parental responsibilities.

I acknowledge and understand that my child cannot be detained under OCGA 15-11-415.

Guardian’s Electronic Signature

Clear

Date

Does this family need a language interpreter?

If “yes” to the previous question, which language?

Reason for CHINS Referral

Child’s Legal Name

Child's Legal Name

First

Last

Child’s Date of Birth

Child’s Preferred Name

Child’s Age

Gender

Gender Conformity Status

Race

Current Phone Number (Cell)

Current Email Address

Address

City

State/Province

Zip/Postal

Country

Parent / Guardian Contact Information

Parent/Guardian: Legal Name

First

Last

Parent/Guardian: Date of Birth

Parent/Guardian’s Age

Parent/Guardian’s Gender

Parent/Guardian’s Gender Conformity Status

Race

Parent/Guardian: Primary Address (If different from above)

City

State/Province

Zip/Postal

Country

Current Home Phone Number

Current Cell Phone Number

Current Email Address

Best Method of Contact:

If the best method of contact is via phone, when would be the best time to do so?

Is DFCS involved with the family?

Yes

If Yes, enter the DFCS Case Manager’s Name:

If Yes, enter the DFCS Case Manager’s Phone Number:

If Yes, enter the DFCS Case Manager’s Email:

What DFCS services are currently in place?

Does the child have any current or past delinquent charges?

Yes

If yes, please provide the date of the charge:

If yes, also provide the county the charge originated from.

Is the child currently being supervised in the community?

Child’s School Information

Child’s School Name (If child is not currently enrolled, input “Not currently enrolled”

Child’s Grade (If child is not currently enrolled, input “Not currently enrolled”

Current Enrollment Status

Does your Child have an Individualized Educational Plan (IEP) or 504 Plan?

Yes

If yes, what modification does the child currently have and how often are the modification being utilized?

Reason for CHINS Assistance

Explain in detail what brought you to Fulton County Juvenile Court’s CHINS unit.

If referred, who referred you to CHINS (Name, Position, and Contact Information)?

Explain in detail what efforts the guardian has made to correct the unruly/ungovernable behaviors.

How do you see the CHINS Program benefiting your child?

Confidentiality and Disclosure Notices

Confidentiality and Disclosure of Client Information:

I understand the CHINS Unit may make referrals to the BH Unit and to outside agencies, community organizations and/or consulting mental health professionals as necessary.

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.

Disclosure Notice:

I understand that as Mandatory Reporters, the CHINS Unit may disclose confidential information, in certain circumstances, without the consent of the client or client’s authorized representative.(Required)

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.

Disclosure Notice:

I have read and understood the information in this document. By signing below, I consent to the release of information to the collective body and community agencies. I also understand that confidential information may be released to agencies/authorities without my permission to protect inviduals from harming self/others or in cases of suspected abuse 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.

Electronic Signature Acceptance

I Accept

Signature: Parent/Legal Guardian/Legal Custodian

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Date Submitted

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