Child Welfare Parenting Assessment Referral Form

230 North Limestone, Suite 100 Lexington, Kentucky 40507
(859) 303-8041 office@heatherriskandassociates.com

This form contains five sections. Please review each section carefully and complete them to the best of your ability. Accurate and complete information will assist us in providing a more comprehensive service.

Today's Date: *

Referral Question

Why are you seeking an assessment? Please be as specific as possible. *

What are you hoping to learn from this assessment? *

Is this a court ordered assessment? *

Yes

If YES - Who is the judge and what county?

Referral Source - Who is completing this form?

Name: *

Organization:

Address:

Email: *

Phone Number(s): *

Can we leave a message? *

Yes

What is your relationship to the referred parent(s)? *

DCBS Worker

Attorney

Self

Relative

Other

Information about the Parents

Name: *

Gender: *

Female

Male

Prefer not to say

Other:

Date of Birth: *

Address: *

Email: *

Phone Number(s): *

Can we leave a message? *

Yes

Second Parent - Information

Check if not applicable

Name:

Gender:

Female

Male

Prefer not to say

Other:

Date of Birth:

Address:

Email:

Phone Number(s):

Can we leave a message?

Yes

Are there other caregivers you would like assessed? Please provide their names and contact information.

Information about the Children

Child's Name: *

Date of Birth: *

Relationship to Referred Parent : *

Who does this child live with currently and relationship? *
Example Response: Jane Doe - Mother or Jon Doe - Relative

Who has custody of this child? *
Example Response: Jane Doe - Mother or Jon Doe - Relative

Email :

Phone Number(s): *

Information about the Children (2)

Child's Name:

Date of Birth:

Relationship to Referred Parent :

Who does this child live with currently and relationship?
Example Response: Jane Doe - Mother or Jon Doe - Relative

Who has custody of this child?
Example Response: Jane Doe - Mother or Jon Doe - Relative

Email :

Phone Number(s):

Information about the Children (3)

Child's Name:

Date of Birth:

Relationship to Referred Parent :

Who does this child live with currently and relationship?
Example Response: Jane Doe - Mother or Jon Doe - Relative

Who has custody of this child?
Example Response: Jane Doe - Mother or Jon Doe - Relative

Email :

Phone Number(s):

Information about the Children (4)

Child's Name:

Date of Birth:

Relationship to Referred Parent :

Who does this child live with currently and relationship?
Example Response: Jane Doe - Mother or Jon Doe - Relative

Who has custody of this child?
Example Response: Jane Doe - Mother or Jon Doe - Relative

Email :

Phone Number(s):

DCBS Information

Has DCBS been involved with this family in the past or currently? Check ALL that Apply: *

Past

Current

None

If DCBS involvement, please provide time in OOHC and nature of maltreatment history (i.e., number of referrals, types of maltreatment, and outcomes substantiated vs. unsubstantiated)

DCBS Worker

Name :

Address :

Email :

Phone Number(s) :

Can we leave a message?

Yes

If the child is in OOHC, describe the visitation arrangement and consistency:

History

Does the parent(s) have a criminal history?

Yes

Unknown

Are there any pending criminal charges? *

Yes

Unknown

If YES - Please explain:

Does the parent(s) have a history of aggressive behavior? *

Yes

Unknown

If YES - Please explain:

Does the parent(s) have a history of suicidal ideations and/or attempts? *

Yes

Unknown

If YES - Please explain:

Does the parent(s) have a history of psychiatric hospitalization? *

Yes

Unknown

If YES - Please explain:

Has this parent(s) ever been accused of sexual abuse or misconduct? *

Yes

Unknown

If YES - Please explain:

Does the parent(s) have a history of experiencing trauma or maltreatment (i.e. domestic violence, childhood abuse, etc.)? *

Yes

Unknown

If YES - Please explain:

Please list all service providers working with the parent.

Please list all service providers working with the child(ren).

Additional Information

Any additional information that would inform your assessment needs?

Is there anything else we should know?

Do you have any questions?