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:

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.

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

Pre-Adoption Services Referral

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: