Appendix L - CSEC Referral Form for Georgia Cares Georgia Cares Referral Form Division of Family and Children Services Fax to: 404-371-1030 or Email to: referrals@georgiacareconnection.com Client’s Information Youth Name: Social Security Number: Date of Birth: Gender: Is client pregnant? ☐ Yes ☐ No Is client actively parenting? ☐ Yes ☐ No Ethnicity: Language Spoken: Does youth have a disability? Who has custody of youth? ☐ Parents ☐ Father ☐ Mother ☐ DFCS ☐ DJJ ☐ Other: If in the custody of DFCS or DJJ, when did custody begin? Client’s Address Legal address: County: Is this youth’s current address? ☐ Yes ☐ No Is this a safe location? ☐ Yes ☐ No Current address (if different): County: Is this a safe location? ☐ Yes ☐ No Contact: Name of legal guardian: Phone number: If youth does not reside with legal guardian, provide the phone number for current placement: Medicaid /CMO ID: Insurance: Please check all that applies: ☐ DJJ Committed ☐Criminal Trespassing ☐Custody of Law Enforcement (Detained by Law Enforcement) ☐DFCS Involvement (Foster Care) ☐DFCS Involvement (Home) ☐Firearm/Weapon Use ☐Frequent Runner (Running 3 or more times in the past 6 months) ☐Gang Involvement ☐ Giving False Name ☐Homeless ☐Loitering for Solicitation ☐On Probation (DJJ or Court) ☐ Police Report ☐Runaway/Unruly Petition ☐Sexual Abuse ☐Sexual Exploitation ☐Shoplifting ☐Substance Abuse ☐Truancy/Suspension ☐Violation of Probation DFCS Referral Information Name of Referral Source: Job Title:
County: Phone Number: Email Address: Case Supervisor Name and Number: Name of Case Worker (If different from referral source): Contact information of Case Worker: DFCS Information Is this youth in DFCS custody? ☐ Yes ☐ No What is the status of the case?☐ Investigative ☐Family Support ☐Placement What is the overall placement history? Date of upcoming Family Team Meeting (if applicable): Date of the next court hearing: What is the purpose of this court hearing? List the services that are currently in place: Describe reason for referral to Georgia Cares: Please attach the following documents: ☐ Release of Information (Required) ☐ Psychological Evaluation ☐ Other applicable documents
Georgia Cares Contact Information Phone: 404–602–0068 (24 hours) Fax to: 404-371-1030 Website: Email to: Georgia Bureau of Investigation, Child Exploitation and Computer Crimes Unit During regular business workdays please call 404-270-8870 and ask for the Child Exploitation and Computer Crimes Unit Agent on call. On nights, weekends, and holidays call the GBI communications center at 404-244-2600 or 1- 800-282-8746 and ask for the Child Exploitation and Computer Crimes Agent that is on call. Attorney General’s Office Human Trafficking Special Prosecutor Camila Wright has been appointed special prosecutor dedicated to the prosecution of human trafficking including the Commercial Sexual Exploitation of Children. Ms. Wright can prosecute and/or provide law enforcement and prosecution assistance on these complex cases. In addition to handling prosecutions, Ms. Write is available to conduct both law enforcement and prosecution trainings and will oversee the Attorney General’s policy agenda on human trafficking. Ms. Wright may be contacted at 404-656-3336 or via email cwright@law.ga.gov.