Referral for Termination of Parental Rights by klutzfu59

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									                                   REFERRAL FOR TERMINATION OF PARENTAL RIGHTS
Name - Worker                                                   Zone / Site                                   Telephone Number

Name - TPR Specialist                                           Zone / Site                                   Telephone Number
                                                                                                              (    )    -
Name - Adoption Worker                                          Zone / Site                                   Telephone Number
                                                                                                              (    )    -
Case Number                                                     Date of Referral                              Date Referral Screened


CHILD
Name                                                                          Date of Birth       Place of Birth

Gender                                                                        Ethnicity


CURRENT PLACEMENT
Placement Type
   Foster Home Conversion               Recruit      Relative
Name - Provider

Address (Street, City, State, Zip Code)                                                                       Telephone Number


PLACEMENT HISTORY
Name - Provider                                   Begin Date                                     End Date



TRIBAL INFORMATION
    Yes          No      Is the child an American Indian?
                         If Yes, name of American Indian Tribe or Band:
    Yes          No      Is the child enrolled or eligible for membership in an American Indian Tribe or Band?
                         If No, who in the family is a registered member?
COURT INFORMATION
Court Number                                                             Date of Original Disposition

Name - Judge                                                             Name - Legal Guardian

Name - Guardian ad litem / Child's Attorney                              Name - Parents’ Attorney


SIGNATURES



                                        SIGNATURE - Worker                                                    Date Signed




                                       SIGNATURE - Supervisor                                                 Date Signed




Referral for Termination of Parental Rights
CFS-2070 (Rev. 06/2008)

								
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