Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-H, 18-6-1-H-VII, app 18-6-1-H-VII-C
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. #)
Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-H, 18-6-1-H-VII, app 18-6-1-H-VII-C