SFN 852, Sending State Priority Home Study Request 619-01-30-10

(Revised 4/18/01 ML #2678)

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PURPOSE: The purpose of SFN 852, Sending State Priority Home Study Request, is to alert the receiving state to the fact that the court which has jurisdiction over the child(ren) has determined that a priority placement of a child from one state into another state is necessary.

 

INSTRUCTIONS: Preparation of the form, together with compilation of other ICPC referral materials, is to be completed within three (3) business days of the receipt of a court order which indicates the court has determined that a Priority Placement situation exists.

 

A separate form is to be completed on each child who is included in the court’s order for priority placement.

 

Name of Child to be Placed: Enter the child's complete name, (last name, first name, and middle initial, if any).

 

Age: Enter the child's age as of the date the form is completed.

 

Mother’s Name: Enter the name of the mother of the child as found on the child's birth certificate.

 

Ethnic Group: Enter the ethnic group to which the child belongs, i.e. Caucasian, African-American, Native American Indian, Hispanic, etc.

 

If the child belongs to more than one ethnic group, enter “biracial” for the child's ethnic group membership.

 

DOB: Enter the child's date of birth as listed on the child's birth certificate.

 

Father’s Name: Enter the name of the father of the child as found on the child's birth certificate.

 

If there is no father listed on the birth certificate, list the name of the alleged father if known, and specify “alleged.”

 

If the child birth father is unknown, enter “Unknown” on this line.

 

PROPOSED CARETAKER: This section relates to the person who will be providing care for the child if placement occurs. The worker should make contact with the proposed caretaker to determine their interest in caring for the child if the court order does not indicate such information.

 

Due to the time constraints for completing the home study, it is essential that all identifying information about the proposed caretaker be included in the request for priority home study.

 

Name: Enter the name (last name, first name, middle initial) of the proposed caretaker.

 

Marital Status: Circle one of the entries to show the marital status of the proposed caretaker, as follows:

 

	S = Single	M = Married	D = Divorced
	W = Widowed	Sep = Separated

 

Living With: Enter the name (last name, first name, middle initial) of the adult person with whom the proposed caretaker is living with, if any.

 

If the proposed caretaker is living alone (without any other adult in the home), leave this section blank.

 

Address: Enter the complete address (street, apartment number, city, state, zip code) of the proposed caretaker.  

 

If the address is a rural route, include the route number and box number of the proposed caretaker.

 

Telephone Home #: Enter the home telephone number, including area code, of the proposed caretaker.

 

If the proposed caretaker does not have a telephone, enter a message telephone number, if possible.

 

If the proposed caretaker does not have a home telephone number or a home message telephone number, enter “None” on this line.

 

Telephone Work #: Enter the work telephone number, including area code, of the proposed caretaker.  

 

If the employer does not allow the employee to receive telephone calls while on duty, specify that information beside the telephone number.

 

If the proposed caretaker is not employed, leave this line blank.

 

Social Security #: Enter the social security number of the proposed caretaker, if known.  Otherwise, leave this line blank.

 

Relationship to Child Identified Above: Self-explanatory.  If applicable specify paternal or maternal to identity which side of the family is involved.

 

Best Time of Day to Contact Caretaker: Enter “a.m.” if the best time to contact the proposed caretaker is between 8:00 a.m. and 12:00 noon (local time of the caretaker).  Enter “p.m.” if the best time to contact the proposed caretaker is between 12:00 noon and 5:00 p.m. (Local time of the caretaker). Enter “evening” and specify the time frame if the best time to contact the proposed caretaker is after 5:00 p.m. and before 9:00 p.m. (Local time of the caretaker).  

 

Employer: Enter the company name of the employer if the proposed caretaker is employed. If the proposed caretaker is not to be contacted at their place of employment, indicate this fact beside the name of the employer.

 

Alternate Contact Name & Address: Enter the name (last name, first name, middle initial) and address (street, apartment number, rural route, and box  numbers, city, state, and zip code) of an alternate person who may be contacted in an effort to make contact with the proposed caretaker. Include the relationship of the contact person with the proposed caretaker.

 

ASSESSMENT OF CHILD: This section relates to the child who will be placed with the proposed caretaker if placement is recommended by the receiving state compact administrator and court approval for placement is given.

 

It is essential that sufficient information be provided to the receiving state worker so that an adequate assessment can be completed which will take into account the needs of the child as well as the capacity of the proposed caretaker to provide appropriately for the child.  

 

Case Plan Attached: Circle “yes” or “no” to indicate if the child's case plan is attached to the referral.  If a case plan has been completed, it must be attached to the referral.

 

Financial/Medical Plan Attached: Circle “yes” or “no” to indicate if the financial and medical plans for the child are attached to the referral.

 

If the proposed placement is with the child's parent, an entry may be made to indicate that the parent will be expected to assume financial and medical responsibility for the child by utilizing private resources or through applying for appropriate public aid.

 

In all other instances, financial and medical plans must be included with the referral to indicate how the child's financial and medical needs are to be met by the proposed caretaker.

 

Special Needs: Enter a description of all special needs which require attention if the child is to be successfully placed with the proposed caretaker. If this information is contained elsewhere in the referral packet, enter the location for the information.

 

Special needs of the child include all medical, physical, emotional, behavioral,  educational, and/or psychological areas of functioning.

 

Handicaps -- Mental/Physical: Describe in detail all mental and/or physical handicaps which the child has and which must be taken into consideration in regard to the capability of the proposed caretaker to adequately care for those  conditions. If this information is contained elsewhere in the referral packet, enter the location for the information.

 

Service Needs/Treatment Needs: Enter all service needs and/or treatment requirements which must be addressed in order to achieve and maintain an acceptable placement of the child with the proposed caretaker.

 

For each service need/treatment requirement listed, include the method by which payment for provision will be obtained, if such information is not included elsewhere in the referral; i.e. case plan, financial/medical plan, etc.

 

School Information: If the child is pre-school age (less than 5) on the date of the proposed placement, leave this section blank.

 

If the child is age 5 or older, enter the following information:

Name of school, grade last attended; report which includes most recent grades; if special classroom attendance is necessary due to the child being learning disabled (LD) or behaviorally disabled (BD); copies of the child's Individualized Educational Plan (IEP), if applicable; recommendations of most recent teacher/counselor/principal regarding educational needs of child; if child is not attending school, give reason(s) for non-attendance.

 

Other Required Pertinent Information Regarding Child and Family Will Follow:  Circle “yes” or “no” to indicate that additional case material will/will not be sent. If “yes” is circled, indicate a tentative date for submitting the additional case material.

 

Worker’s Name: Enter the name (first name, last name) of the worker who completed this form.  The information is to be printed.

 

Telephone Number: Enter the worker’s telephone number including area code. If applicable, include the extension number.

 

Worker’s Signature: Self-explanatory.

 

Date Signed: Self-explanatory.

 

Supervisor’s Signature: If required by local office policy, enter the signature of the immediate supervisor of the worker.

 

Date Signed: Self-explanatory.