Carolina Family Services, Inc

“Because ALL Families Matter”

Testimonials

To make a referral for Child Conferencing Program, fill out the form below, and click the Send button.

Child(ren)'s Name(s)	DOB	Placement Name, Phone #, and Address	Child(ren)'s Medical Issues, Special Needs, Services, Etc	Alternate Caregiver Relation to Child(ren)	Alternate Caregiver DOB

Other Family/Friends For Possible Placement	Relation Child(ren)	DOB	Phone #	Address

Has FF and CC been explained to the family?
Form Completed By:

Date and Time of Referral:
Case/Family Name:
CPS #:

Referring DSS Worker:
Work Phone:
Cell Phone:
Email Address:

DSS Supervisor:
Work Phone:
Cell Phone:
Email Address:

Harm, Allegations and Notes: (court dates, concerns, other important information)
Date DSS Case Opened:
Case Status:		Investigation Foster Care Treatment Other:
Purpose of Referral:		Early FF and CC Front End FF and CC Back End FF and CC Re-conferencing
Any Protective Orders (TRO)?
If Yes, explain:
Family Ethnicity:		African American Asian Biracial American Indian Caucasian Hispanic/Latino Other:
Primary Language of Family:
Will an interpreter be needed?
If Yes, explain: