E attach copy of DSS Family Strengths and Needs Assessment) Date of DSS Referral: Services : Date of DSS Finding of Substantiation or In Need of Basis of Substantiation or In Need of Services : Child s Name: Date of Birth: Male Female : Race/Ethnicity: Language, if other than English: Address: Telephone Number: Referring County Department of Social Services: DSS Contact Person Telephone: Parent/Caretaker Name: (If parent is not legal guardian, list who has legal cus.
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How to fill out the NC DSS-5238 online
Filling out the NC DSS-5238 form is an essential step in accessing early intervention services for children who may need support. This guide provides detailed, step-by-step instructions to help users complete the form efficiently and accurately.
Follow the steps to fill out the NC DSS-5238 form online.
- Click the ‘Get Form’ button to obtain the form and open it in the online editor.
- Begin by entering the date of the DSS referral at the top of the form. Ensure this date is accurate as it is critical for tracking purposes.
- Fill in the child's name and date of birth. Use the dropdown or selection format for gender, and select the appropriate option.
- Complete the address section alongside a telephone number for easy communication.
- Indicate if the parent or caretaker has any known physical or mental health issues.
- Answer if there have been any prior assessments for medical or developmental needs, specifying by whom.
- Provide the name and contact information for the child's primary medical provider.
- Answer whether the child has Medicaid/HealthChoice or other insurance.
- Include any additional information that may assist the Child Developmental Service Agency in understanding the family’s needs.
- Provide directions to the family's home to aid in any necessary follow-up visits.
- Once all fields are filled out, save your changes. You can download, print, or share the form as needed.
Begin filling out the NC DSS-5238 form online today to ensure timely access to early intervention services.
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