PSSF Services PSSF Placement Prevention Intake and PreScreen Form Intake form for all PSSF Placement Prevention cases served through GTS. Referral Source (original source if internal)DFCS - OFIDFCS - Intake (screen out)DFCS - InvestigationsDFCS - Family Support ServicesDFCS - Family Preservation ServicesDFCS - Foster CareDFCS - Foster Care ILPDFCS - Resource DevelopmentDFCS - AdoptionsFaith-Based InstitutionHealth DepartmentHospitalJuvenile Court/Family CourtLaw EnforcementMental HealthOther Community AgencyPrevious or Current ParticipantProbationSchoolSelfShelterFamily Status at Time of ReferralCPS InvestigationOpen CPS Family PreservationOpen CPS Family SupportClosed CPSChildren in Foster CareChildren in Relative Custody/GuardianshipYouth in Foster Care - ILPYouth in Extended Support ServicesClosed Foster CarePre-Adoptive PlacementPost-AdoptionDFCS OFI OnlyScreen Out History OnlyNo Current CPS InvolvementReferral Name Referral Phone Referral Email Services Requested Assessment Case Management Therapy Therapeutic Behavior Management Parent Education Life Skills Issue(s) of Focus Physical Neglect Sexual Emotional Substance Abuse Other Other (describe): Section BreakFirst Name Last Name SSN (last 4 digits)Date of Birth (MM/DD/YYYY) Street Address City State Zip County Marital StatusCohabitatingDivorcedMarriedSeparatedSingleWidowedEducationCollege DegreeElementary (1-8)GEDHigh School DiplomaSome CollegeVocational TrainingEthnicityAfrican-AmericanAmerican IndianAsianCaucasianHispanicOtherIncome Sources (check all that apply) Full-Time Employment Part-Time/Seasonal Employment TANF Child Support (non-custodial parent) Other Income (alimony, interest, dividends, etc.) SSI (supplemental security income) SS (social security benefits) Private Disability Insurance VA (veteran's administration) Unemployment Benefits Food Stamps WIC Workman's Compensation Retirement/Pension Relative Subsidy Adoption Assistance Estimated Income from all Sources$10,000 - $19,000$20,000 - $29,000$30,000 - $39,000$40,000 - $49,000$50,000 +Section BreakFirst Name (Parent 2) Last Name (Parent 2) Section BreakFirst Name (Child 1) Last Name (Child 1) Developmental Disability? Yes SexFemaleMaleOtherDate of Birth (mm/dd/yyyy) EducationInfant/Toddler (ages 0-2)Preschool (ages 3-5)Elementary (grades K-8)High School (grades 9-12)Other Educational EnvironmentNot in SchoolFirst Name (Child 2) Last Name (Child 2) Developmental Disability? Yes SexFemaleMaleOtherDate of Birth (mm/dd/yyyy) EducationInfant/Toddler (ages 0-2)Preschool (ages 3-5)Elementary (grades K-8)High School (grades 9-12)Other Educational EnvironmentNot in SchoolFirst Name (Child 3) Last Name (Child 3) Developmental Disability? Yes SexFemaleMaleOtherDate of Birth (mm/dd/yyyy) EducationInfant/Toddler (ages 0-2)Preschool (ages 3-5)Elementary (grades K-8)High School (grades 9-12)Other Educational EnvironmentNot in SchoolFirst Name (Child 4) Last Name (Child 4) Developmental Disability? Yes SexFemaleMaleOtherDate of Birth (mm/dd/yyyy) EducationInfant/Toddler (ages 0-2)Preschool (ages 3-5)Elementary (grades K-8)High School (grades 9-12)Other Educational EnvironmentNot in SchoolFirst Name (Child 5) Last Name (Child 5) Developmental Disability? Yes SexFemaleMaleOtherDate of Birth (mm/dd/yyyy) EducationInfant/Toddler (ages 0-2)Preschool (ages 3-5)Elementary (grades K-8)High School (grades 9-12)Other Educational EnvironmentNot in SchoolSection BreakDate of Initial Assessment (mm/dd/yyyy) Assessment Tool(s) Used FAST Assessment AAPI NCSI Biopsychosocial Additional/Other Other Assessments Used: Δ
