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 * signature keyboard Clear Date * Does this family need a language interpreter? * YesNo If “yes” to the previous question, which language? Reason for CHINS Referral Unruly/UngovernableRunawayTruancy (if selected, refer to Truancy Protocol) Child’s Legal Name Child's Legal Name First First Last Last Child’s Date of Birth Child’s Preferred Name Child’s Age * Gender * MaleFemaleNon-Binary Gender Conformity Status Gender ConformingTransgender Race * African-AmericanAsianLatino/HispanicMixed RaceWhite Current Phone Number (Cell) Current Email Address Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Parent / Guardian Contact Information Parent/Guardian: Legal Name * Parent/Guardian: Legal Name First First Last Last Parent/Guardian: Date of Birth * Parent/Guardian’s Age * Parent/Guardian’s Gender * MaleFemaleNon-Binary Parent/Guardian’s Gender Conformity Status Gender ConformingTransgender Race * African-AmericanAsianLatino/HispanicMixed RaceWhiteAmerican IndianAmerican Indian Pacific Islander Parent/Guardian: Primary Address (If different from above) Parent/Guardian: Primary Address (If different from above) Parent/Guardian: Primary Address (If different from above) Parent/Guardian: Primary Address (If different from above) City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Current Home Phone Number Current Cell Phone Number Current Email Address * Best Method of Contact: PhoneEmail If the best method of contact is via phone, when would be the best time to do so? MorningsEvenings Is DFCS involved with the family? * Yes No 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 No 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? YesNoN/A 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 EnrolledExpelledHome Schooled Does your Child have an Individualized Educational Plan (IEP) or 504 Plan? Yes No 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 * signature keyboard Clear Date Submitted * Submit If you are human, leave this field blank. Δ
