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Out of County Services Transmittal by ajizai

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									    1      Alachua                  Black/African Amer.   Jan   Parent
  2A       Baker                    White/Caucasian       Feb   Non-Relative
  2B       Bay                      Asian                 Mar   Relative
    3      Bradford                 Pacific Islander      Apr   Foster
    4      Brevard                  Native American       May   Adoption
Suncoast   Broward                                        Jun   Other
    7      Calhoun                                        Jul
    8      Charlotte                                      Aug
    9      Citrus                                         Sep
   10      Clay                                           Oct
   11      Collier                                        Nov
   12      Columbia                                       Dec
   13      Dade
   14      DeSoto
   15      Dixie
           Duval
           Escambia
           Flagler
           Franklin
           Gadsden
           Gilchrist
           Glades
           Gulf
           Hamilton
           Hardee
           Hendry
           Hernando
           Highlands
           Hillsborough
           Holmes
           Indian River
           Jackson
           Jefferson
           Lafayette
           Lake
           Lee
           Leon
           Levy
           Liberty
           Madison
           Manatee
           Marion
           Martin
           Monroe
           Nassau
           Okeechobee
           Okaloosa
           Orange
           Osceola
           Palm Beach
           Pasco (East/Dade City)
Pasco (West/New Port Richey)
Pinellas
Polk
Putnam
Santa Rosa
Sarasota
Seminole
St. Johns
St. Lucie
Sumter
Suwannee
Taylor
Union
Volusia
Walton
Wakulla
Washington
                                                  Out of County Services Transmittal
                                         FROM DISTRICT
To (District/Region):                                  To (County):                                                                   Request Date:
FSFN CASE ID #:                   DON'T FORGET TO ENTER FSFN #
Child's Full Name                                                                    DOB                Sex            Race                 FSFN Person ID Number




Services Requested/Performed By:
Lead Agency:
Sub Agency:
Case Manager:                                                                                   Supervisor:
Phone:                                                                                          Phone:
Email:                                                                                          Email:
Fax:                                                                                            Fax:
Prospective Placement/Facility (list all adults in home)        Relationship to Child                                  Address                               Phone #




All Requests:                     Detailed Cover Letter     (See Sample Cover Letter)
Home Study Request Type:
   Current Court Orders-showing legal status & any court activity since last JR                    Any Psychological Evaluations/CBHA/IEP
   JRSSR or PDS & Shelter Order if no JR (within last 6 months)                                    Current Case Plan
   Abuse/Neglect Reports          CSA           FAHIS                                              School records (if appropriate)
    For Adoption HS Requests:           TPR Orders (Required)                     Child Study      Photo of Child
   Out of County Supervision:                              All Licensed Placemements, DJJ Facilitiess & requests without previous HS should include all above attachments
                       Copy of the HS (If not completed by receiving agency)                                      Updated court orders (since original request)
             Date of Last Visit                   Month next visit needed:                                        Visit Frequency:
   Case Plan Assistance                 Case Plan                     JRSSR or PDS & Shelter Order if no JR (within last 6 months)       Psychological Evals/CBHA/IEP
   Completed HS:                        APPROVED                                       DENIED
                               Termination of Out of County Supervision (please include court order if applicable)
                                         Case                                                                                                                     Lead Agency
                                        Manager                                                      Supervisor                                                   or Zone Spec




                                                                                                                                                       Revised 4/22/08
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achments



HA/IEP




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     1    Alachua                                             Native Am.
     2                          January Non-Relative
                                February Parent
                      White/Caucasian
          Baker                                               Asian
     3    Bay                      March   Relative           Black/African Amer.
     4                             April
                      Pacific Islander     Foster
          Bradford                                            White
SC        Brevard                  May     Adoptive           Hispanic
     7    Broward                  June                       Pacific Islander
8         Calhoun               July                          Other
9         Charlotte             August
10        Citrus                September
11        Clay                  October
12        Collier               November
13        Columbia              December
14        DeSoto
     15   Dixie
          Duval
          Escambia
          Flagler
          Franklin
          Gadsden
          Gilchrist
          Glades
          Gulf
          Hamilton
          Hardee
          Hendry
          Hernando
          Highlands
          Hillsborough
          Holmes
          Indian River
          Jackson
          Jefferson
          Lafayette
          Lake
          Lee
          Leon
          Levy
          Manatee

          Marion
          Martin

                                                       Revised 4/22/08
Miami-Dade
Monroe
Nassau
Okaloosa
Okeechobee
Orange
Osceola
Palm Beach
Pasco
Pinellas
Polk
Putnam
Santa Rosa
Sarasota
Seminole
St. Johns
St. Lucie
Sumter
Suwannee
Taylor
Union
Volusia
Wakulla
Walton
Washington




             Revised 4/22/08
            Male      Y
            Female    N
Black/African Amer.

Pacific Islander




                          Revised 4/22/08

								
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