Mississippi Administrative Code › Title 18 - HUMAN SERVICES › Part 6 - Division of Family and Children's Services › Chapter 1 - DFCS Policy Manual › Section 18-6-1-H - Interstate Compact on the Placement of Children › Section 18-6-1-H-VII - APPENDICES › Appendix 18-6-1-H-VII-C - Sending State Priority HOME Study Request

Current through June 25, 2024
To be submitted by Social Worker with other required ICPC
						materials
Name of Child1
						______________________________________ Age ________ Mother's Name
						_______________________________________
Ethnic Group ________________________________________ DOB
						_____________________ Father's Name __________________________
PROPOSED
						CARETAKER
NAME: ______________________________________ Marital
						Status: S, M, Sep., D, W Living with ________________________________
(name of person) ADDRESS:
						_____________________________________________________________________________________________________________________
Telephone Home #: _____________________________ Work #:
						_______________________ Social Security # ________________________
Relationship to child identified above:
						___________________________________________________________
Best time of day to contact caretaker: ________________
						Employer ____________________________________________________________
(If applicable) Alternate Contact Name &
						Address:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
ASSESSMENT OF
						CHILD
Case Plan Attached: Yes No (circle one) Financial/Medical
						Plan attached: Yes No (circle one)
Special Needs:
						_____________________________________________________________________________________________________________________
Handicaps: Mental/Physical
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Service Needs/Treatment Requirements:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
						.
School Information:
_____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
						.
Other required pertinent information regarding child and
						family will follow: yes no (circle one)
Worker's Name:
						_____________________________________________ ________________________
(please print) (Tel. #)
Worker's Signature:
						__________________________________________ __________________
(date)
Supervisor's Signature:
						_______________________________________ __________________
						_______________________
(if required) (date) (Tel. #)