E attach copy of DSS Family Strengths and Needs Assessment) Date of DSS Referral: Date of DSS Finding of Substantiation or In Need of Services : Basis of Substantiation or In Need of Services : Child s Name: Date of Birth: Male Female : Race: American Indian/Alaskan Native Asian Black/African American Pacific Islander White Ethnicity: Hispanic or Latino Not Hispanic or Latino Language, if other than English Address Native Hawaiian/Other Telephone Number: Referring Co.
Open form follow the instructions
Easily sign the form with your finger
Send filled & signed form or save
How to fill out the NC DSS-5238 online
Filling out the NC DSS-5238 form online can help ensure that children in need of early intervention services receive timely support. This guide provides a clear and concise walkthrough of each section of the form to facilitate a smoother completion process.
Follow the steps to successfully complete the NC DSS-5238 form.
- Click the 'Get Form' button to access the NC DSS-5238 form and open it in your preferred editing tool.
- Enter the date of the DSS referral at the top of the form. This records when the referral is being made.
- Input the date of the DSS finding of 'Substantiation' or 'In Need of Services.' This is crucial for tracking the timeline of actions taken.
- Provide the basis of 'Substantiation' or 'In Need of Services.' This information helps clarify the reasons for the referral.
- Fill in the child's name and date of birth to identify the individual receiving support.
- Indicate the child’s gender and race by selecting the appropriate options provided on the form.
- Specify the child’s ethnicity and any language preference, if other than English, to support effective communication.
- Complete the address and phone number fields to ensure the service providers can contact the family.
- Identify the referring county department of social services and provide the contact person's information.
- Document the parent or caretaker's name and, where applicable, the legal guardian's contact details.
- Answer the questions regarding any known or suspected health problems of the parent or caretaker, as well as their involvement with other agencies.
- Detail any prior assessments for medical or developmental needs, including who completed them.
- Indicate if the child has any diagnosed or suspected developmental delays or special needs.
- Provide the primary medical provider's contact information, including telephone number or address.
- List any other social service agencies or medical providers currently involved with the child.
- Check off whether the child has Medicaid/HealthChoice and any other insurance information as applicable.
- Confirm if the family has been informed about the CDSA referral, as this must be established prior to the referral.
- Add any additional information that may assist the Child Developmental Services Agency in understanding the family's situation.
- Finally, provide directions to the family's home to facilitate any necessary visits.
- Upon completing the form, ensure to save your changes. You may also choose to download, print, or share the form as needed.
Complete your NC DSS-5238 form online today to ensure timely support for children in need.
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Related content
DSS Referral Form for Early Intervention Services (CDSA) ... Referring County Department...
2021-22 NC County Salary Survey. A, B, C, D, E, F, G, H, I ... Social Services Director...
... 5238 SBl1-5235 SB21-1590 GB21-1647 SB21-1648 SB21 ... 2019 GC33-2022 GC33-5384...
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
If you believe that this page should be taken down, please follow our DMCA take down process here.