DHS-ORS-CIC-CPAR

New 03/05 Revised 08/29/05

24-HOUR DSPD COMMUNITY PLACEMENT ORS REFERRAL

*Please complete this form when the child is placed into 24-hour care and send it to the

address below or fax it to 801-536-0378.

CHILD’S INFORMATION

CHILD’S NAME: ___________________________________________ SS#: ______________________

DOB: __________________ SEX: M___ F___ DATE OF ADMISSION: ___________________

CASE MGR NAME: __________________________________________PHONE: _________________

NAME OF PLACEMENT: _____________________________________PHONE:__________________

ADDRESS OF PLACEMENT: ____________________________________________________________

____________________________________________________________

FATHER’S INFORMATION

FATHER’S NAME: _________________________________________SS#:________________________

DOB: _____________ PHONE: __________________________

LAST KNOWN ADDRESS:_______________________________________________________________

LAST KNOWN EMPLOYER:________________________________PHONE:______________________

EMPLOYER ADDRESS: _________________________________________________________________

_________________________________________________________________

MOTHER’S INFORMATION

MOTHER’S NAME: _________________________________________SS#:________________________

DOB: ____________ PHONE: _____________________________

LAST KNOWN ADDRESS:_______________________________________________________________

LAST KNOWN EMPLOYER: _________________________________PHONE: ____________________

EMPLOYER ADDRESS: _________________________________________________________________

_________________________________________________________________

OFFICE OF RECOVERY SERVICES

CIC TEAM 77

P.O. BOX 45011

SALT LAKE CITY, UTAH 84145-0011

FAX: 801-536-0378

FOR INFORMATION REGARDING PARENT ASSESSMENTS CONTACT ORS AT 536-8817