Adoption Services Referral Form

Services Requested:*
- Child/Family Prep
- Child Recruitment
- Assist with finalization paperwork (excluding WWK)
Please select all that apply.
Date Entered Care:*
OASIS Client ID Number:*
OASIS Case Number:*
Child's Name*
First
Child's Name
Middle
Child's Name*
Last
Date of Birth:*
Gender:*
If selected "Other," please explain how they identify:
Race:*
Is the child Hispanic or Latino?
- Yes
- No
A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Termination of Parental Rights:
Father:
Appeal?
- Yes
- No
Date Final:
Mother:
Appeal?
- Yes
- No
Date Final:
Is this child six years old or older?
- Yes
- No
*Please note that if a child under the age of six does not meet two or more of the following criteria, a special approval request (SAR) must be made to VDSS by DePaul Community Resources prior to opening the case. VDSS approval to open a SAR case is not guaranteed.
Please list the special needs of this child:
- Physical, mental, or emotional condition existing prior to foster care
- Hereditary tendency, congenital problem, or birth injury leading to substantial risk of future disability
- Member of a minority group based on racial, multi-racial, or ethnic heritage
- Close relationship with one or more siblings and the siblings will be placed together
Please explain:
*If "siblings" box checked, please provide their name and date of birth.
If a child under the age of six is being referred & is not placed with sibling(s), please note why your agency is requesting assistance:
- Not applicable as the child is age six or older or is under age six and placed with sibling(s)
- Agency is short-staffed
- No workers are trained to complete the adoption process
- Worker caseloads are high
- Other
If you chose "Other," please explain:
Child's Current Placement Type:
- LDSS Home
- TFC Home
- Residential Placement
- Other
If you chose "Other," please explain:
TFC Agency Name and Worker Name*
TFC Worker Phone*
TFC Worker Email*
Potential Adoptive Placement?
- Yes
- No
Adoptive Placement Agreement Signed?
- Yes
- No
Date Signed
Placement Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Date Child Entered Current Placement
Please list any other important information:
Please Read and Check Below Indicating Agreement With and Consent to the Following:
DePaul Community Resources has permission to photograph and/or videotape the child/children referred and to feature them in the media, including internet, television, print, radio, electronic and other public venues, for the purpose of locating an adoptive family.
- Publication
DePaul Community Resources has permission to photograph and/or videotape the child/children referred and to feature them in the media, including internet, television, print, radio, electronic and other public venues, for the purpose of locating an adoptive family.
DePaul Community Resources agrees that the use or disclosure of any information concerning children or families serviced by DePaul Community Resources will be used for adoption purposes only.
- Confidentiality
DePaul Community Resources agrees that the use or disclosure of any information concerning children or families serviced by DePaul Community Resources will be used for adoption purposes only.
Acknowledgement of Privacy Practices:
I acknowledge that I have reviewed the agency’s privacy practices outlined below.
ADOPTION SERVICES AGREEMENT
ACKNOWLEDGMENT OF PRIVACY PRACTICES:

GRIEVANCE PROCEDURE
Your input regarding the services provided by DePaul Community Resources’ Adoption Program is important. If you are not satisfied with services provided, it’s important to let the Adoption Specialist managing the case know of your concerns. You may also contact Marya McPherson, Director of Adoption, at 540-381-1848 or Renee Brown, Vice President of Child and Family Services of DePaul Community Resources. Renee can be reached at 540-265-8923.

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CONFIDENTIALITY
Protecting confidentiality is important to DePaul Community Resources. All client information is confidential. On the referral application, you have been asked to give permission for the referred child to be featured in the media for recruitment purposes.
Written permission to release client-related information to outside parties for other purposes is required by law, except in the following cases:
1) Mandated reporting of abuse, neglect, self-harm, harm to others, duty to warn of threat to harm others, or client inability to care for self.
2) Medical emergency; for the purpose of preventing injury to or death of client or another person
3) Subpoena for records, legal counsel, hearings, reviews, appeal or investigation under the regulations of Licensing, Human Rights, or certification or accreditation. (12 VAC 35-115-80)

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CLIENT RIGHTS
DePaul Community Resources respects the rights of children receiving services.
Clients being served have the right….
• to be treated with dignity and respect
• to be told about their treatment
• to have a say in their treatment
• to speak to others in private
• to have their complaints resolved
• to say what they prefer
• to ask questions and be told about their rights
• to get help with their rights

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Initial Here*

Providing your initials above represents your digital signature for this form.
Date
DSS Agency*
DSS Worker*
DSS Worker Email*
Phone

Termination of Parental Rights:

Please list the special needs of this child:

Please Read and Check Below Indicating Agreement With and Consent to the Following: