Child Information
Child's First Name
Child's Last Name
Date of Birth
Social Security Number
Gender
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Male
Female
Other
Other Gender
Race
Select Option
Refused to Disclose
Black/African American
Am Indian/Alaska
Native Hawaiian or Other Pacific Islander
White
Asian
Other
Other Race
Tribal Affiliation - Please select other for N/A
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Ak-Chin Indian Community
Chickasaw Nation
Cocopah Indian Tribe
Colorado River Indian Tribe
Fort McDowell Yavapai Nation
Fort Mohave Indian Tribe
Fort Yuma Quechan Tribe
Gila River Indian Community
Havasupai Tribe
Hopi Tribe
Hualapai Tribe
Kaibab Band of Paiute Indians
Native American Distinction
Navajo Nation
Oglala Lakota Nation (Pine Ridge)
Pascua Yaqui Tribe
Pueblo of Zuni
Salt River Pima-Maricopa Indian Community
San Carlos Apache Tribe
San Juan Southern Paiute Tribe
Tohono O' Odham Nation
Tonto Apache Tribe
White Mountain Apache Tribe
Yavapai- Apache Tribe
Yavapai- Prescott Indian Tribe
N/A
Other Tribal Affiliation
Ethnicity
Select Option
Hispanic
Latino
Other
N/A
Other Ethnicity
Preferred Language
Select Option
English
Spanish
Other
Other Language
Case Numbers
DCS Case Number
AHCCCS ID
MC DCS CHP ID/PI#
Behavioral Health
If DCS has a preferred Assigned Behavioral Health Clinic (ABHC), list here: (If different from physical address). Otherwise put N/A.
Does the child have a current behavioral health provider?
Select Option
Yes
No
Unknown
Provider Name
Sibling Group
Is the child part of a sibling group being referred for a Rapid Response?
Select Option
Yes
No
N/A
How many siblings in the Rapid Response?
Names of Siblings?
Removal Information
Date of Removal/Dependency
Time of Removal/Dependency
City/Location of Removal
Reason for removal from family
Concerns for the Child
In CRS?
Select Option
Yes
No
In DDD?
Select Option
Yes
No
Any known concerns for the child? (mental health, medical, development, etc.)
Select Option
Yes
No
Provide additional information if yes for DDD, CRS or Known Concerns.
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Placement Information
Type of Placement
Out-of-county placement?
Select Option
Yes
No
Name of Placement
If placement is a foster or group home, name of licensing agency (if known). Otherwise put N/A.
If relative placement: What is the relationship to the child? Otherwise put N/A.
Placement Street Address
City
State
Zip
County
Primary Phone
Secondary Phone
School/Daycare
School/Daycare Phone
Special Instructions
DCS Information
DCS Specialist Name
DCS Specialist Phone
DCS Specialist Email
DCS Supervisor Name
DCS Supervisor Phone
DCS Supervisor Email
DCS Office Street Address
City
State
Zip
County
DCS County of Jurisdiction
Has there been prior DCS involvement?
Select Option
Yes
No
Office of Child Welfare Information
Involvement by the Office of Child Welfare Investigations?
Select Option
Yes
No
Contact Name
Email
Phone
Forensic Interview Information
Is there a forensic interview scheduled for the child?
Select Option
Yes
No
Date of Forensic Interview
Time of Forensic Interview
Provide Any Additional Information
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Parent Information
Parent One
Name
Relationship to Child
Date of Birth
Language Preference
Placement Address
City
State
Zip
County
Primary Phone
Add Another Parent?
Select an Option
Yes
No
Parent Two
Name
Relationship to Child
Date of Birth
Language Preference
Placement Address
City
State
Zip
County
Primary Phone
Parent Involvement
Are there restrictions to parent involvement with the child, including assessment, Child and Family Team, treatment/services?
Select Option
Yes
No
Provide detailed restrictions
Can the Rapid Response team contact the parents to engage them in services including the assessment, Child and Family Team?
Select Option
Yes
No
Yes
No
Has a team decision-making meeting occurred or been scheduled?
Select Option
Yes
No
Date of Team Meeting
Time of Team Meeting
Meeting Address
City
State
Zip
County
Previous
Review
Review and Confirmation
Consent
I acknowledge and consent that the Rapid Response Team can provide routine evaluation/treatment services
I consent
I do not consent
Individual requesting the referral
Position
Email
DCS Staff Signature
Referral Date
Would you like to edit the form to add an additional child?
Select One
Yes
No
Drag & Drop files here or Click to upload.
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