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L  *>> (_17  2( 4 <DL223  Ԁ2( 4 <DL2  *DD (_16   ," <DL,23  Ԁ," <DL,   *55 (_15  ) <DL)23  Ԁ) <DL)  *22 (_14 ` &<<DL&23  Ԁ&<<DL& ` *// (_13  #DL#23  Ԁ#DL#  *,, (_12   DL 23  Ԁ DL  #;JA X Cdd*)) (_11 h DDL23  ԀDDL h *&& (_10  L23  ԀL  (## &_9   L23  Ԁ L  (>> &_8  2( 4 <DL223  2( 4 <DL2  (DD &_7   ," <DL,23  ," <DL,   (55 &_6  ) <DL)23  ) <DL)  (22 &_5 ` &<<DL&23  &<<DL& ` (// &_4  #DL#23  #DL#  (,, &_3   DL 23   DL  ()) &_2 h DDL23  DDL h (&& &_1  L23  L  &## $_   L23   L  <:Default Para>Thick Double Pd Pd<Wavy Double^ H d d/Wavy Single  d d dn-#oE<<C Level 1Level 2Level 3Level 4Level 5($$   1  ''''3 ShadowdZd !x XXo  _qqx bqqTRX3'Avery 23280 BIG TAB InserX3' Letter3'Letter3280 BIG TAB Inser TAB Inser3'LetterT-b*23ddd Xdd Xdd X%%,-dd ,sdd +  ) q)b-  StateofKansas#-b@# <d b-DepartmentofSocialandRehabilitationServices#-b#  b-ChildrenandFamilyServices#-b9#_  ԍ 4\  @  @   _ 4\  _  @l#l#FX%CFS2020 <d @R"R"@X%_Rev.January_Ԁ2007   @w  @  @'  @  @  @/  @  @  @7  @" Page1of1'8`0 q '#qq-#-qq'*xdd-dd -sdd s23%%x,#dd +  1 )IqIq e)1T C-@O O FAMILYPRESERVATIONREFERRALANDTRANSMITTALSHEET#-C# ' e '*l45d/d#dd #%%l,Vdd ,dd ,dd ,dd ,Kdd ,,dd ,9dd ,dd ,Bdd ,,dd ,dd ,*dd +  ) ),b- Headof :  ̀Household: #-,b; # )'.  ) .': ' . 0&: ' 0,b- 6''''#!:  6^ 1':'''' 1Initial : Referral -# - 6''''#!: 6^ ^ 4*:'''' 4Resumptionof : ЀIntensiveServices   C9)Rz   OC   ! !LastName +! +FirstName#-,bE #,b-#,qq,b#,bq,q <2)yy <MI B8)yy B 6,&yy 6Dateand#,qq,b1#,bq,q#-,b #,b-   ̀Timeof w# Initial 7 _& Referral:#,qq,b2##qqq,qt#,qqqq,bq,q 1'   ) 1 <2)*yy' <#-,b9#,b-DATEof#-,b#,b-Ԁresumption#-,bP#,b-#,qq,bX#,bq,q + ̀ofintensiveservices: w. Ѐ / NOTE:NoFACTS 7 _1 entryrequired#-,b#,b-,Only   4 ̀_eSCRIPTS_#,qq,b#,bq,q#-,b#,b- C'2, 7 C H>.8yy O ' wHdAddressof  . 9 Family:dd %' < %d +! . =' + .$ = . 4* = 4   =  #'  = # .$ =' . 2'! = 2 :0  = w ' !:dPhonenumber  ' > orcontact#  A  forfamily#-,b##qq-A#-qq,b-: %' D %d . ' G' '#-,b#,b-#,qq,b#,bq,q'#-,bs##qq-#,qqqq,bq,qԈ ' ' P ' 1' ' Q 1 ! ' R !#,qq,bK##qqq,q,#-qq,b-  ? g T #-,bJ##qq-+#-qq,b- +! [ +#-,b##qq-#,qqqq,bq,q * ? g ] * 7- ' ^ !  7FACTS _ ̀CASEID#: %'b %#-,b}##qq-#,qqqq,bq,q 'g' 'County 1Yi (Family)#,qq,b#,bq,q#-,b#,b-:@# +'l + +!p' + @1 #,qq,bb#,bq,q#-,b#,b- 'q 'Local r ̀_SRS_ u ̀Office: ' qx   9 #-,b##qq-_#-qq,b- * y' *@'$'$M'$ 7-z   7_KAECSES_#:#-,b#,b- ('c{ (#-,b#,b- $c|' $_SRS_ԀSocial c} ̀_Wkr_: ,'   ,  @2 4*$c' 4#-,b" ##qq-#,qqqq,bq,q  c #-,b!#,b-^}  ?5.c    ?_SRS_ԀRegional - Office ' % #-,b"#,b- . $-' $dSW - ̀PHONE/CELL % ̀PHONE#: ,'  ,d     n 4*$-' 4#-,b###qq-!#,qqqq,bq,q ( - (0&$    0*=67d dVdd Vdd dd dd Kdd K,dd ,9dd 9dd Bdd B,dd ,dd *dd *45%%=,dd ,,dd ,dd ,,dd ,dd ,,dd ,dd ,,dd ,dd ,,dd ,dd ,Xdd , dd +  : $ $:'Region(Mark ?g One) '^^^^3[ '^ LB?g^^^^  ?1?L1 E^^^^20?g  ?1 ? E LB?g^^^^  @2@L2 E^^^^20?g  @2 @ E LB?g^^^^  @3@L3 E^^^^20?g  @3 @ E LB?g^^^^  @4@L4 E^^^^20?g  @4 @ E LB?g^^^^  @5@L5 E;0?g  @5 @ E Referredto: ?g (Provideragency) %'' %(?g ' (^J(#-,bv$#*P '  d ddd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd Xdd X dd  67%%P,,dd ,dd ,wdd ,Fdd ,dd ,wdd ,edd ,wdd ,wdd , dd +  -#??  -v SECTIONI @)) FINANCIALELIGIBILITY:(Checkallthatapply)  /^^^{    / 4*^^^ 4Employer: I''6$ I A'2$'' A =3!' =PrivateInsuranceCompany  Name >'-$/W > 7-' 7 Phone# <'')$ < 4'#'' 4 9/!9a' 9b- Policy 9a Number ;'*! ; 0^^'^)Q' 0#-b1# ;'*9a^^'^ ;v.TitleIVE 9a ̀_TAF_ |   v 9^^'^&$5]' 9 9'&9a^^'^ 9TitleXIXMedicaid/TitleXXI 9a ̀_HealthWave_#qq-$#-qqv31'%  ' 1*d  d,dd ,dd wdd wFdd Fdd wdd wedd ewdd wwdd w dd ' %%, dd(,,dd ,dd(,,dd ,dd ,,dd ,dd(+  b-^ $ $SECTIONII#-b_6#b-0 0 PRESENTING?g0 0  Ѐ  ЀPROBLEM: 0^^^^ 0#-b6#b-^~6v< 6,!?g^^^^ 6Abuse 0^^^^?g 0 6,!?g^^^^ 6Neglect 0^^^^?g 0 6,!?g^^^^ 6NonAbuseorNeglect#-b7#"?g "v<8*d/d dd( ,dd ,dd(,dd ,dd ,dd ,dd(%%,dd ,dd ,wdd ,dd ,wdd ,dd ,dd ,dd ,|dd ,|dd +  (MuMu (#qq-4#lqqB l^Isthereachild(_ren_)inthisfamilywho  isin_SRS_Ԁcustody? ?^^^^,&q   ?#qq B;#bqq B8)yy^^^^ BNO <^^^^)#yy < B8)yy^^^^ BYES(If_Yes,list_  Ѐ  ̀names)#-b<#b- =',&q  = 4*' 4 %^^^^ ? g % 4*? g^^^^ 4 %^^^^ ? g % 4*? g^^^^ 4 #' ? g #  #-b>##qq-'=#-qqb- 4* ' 4#qqb[@#B qqIfthereiscustody,whenisthenextcustody !  ̀caseplandue? @'/&U"}!_ @#qq B@#bqq H>,! yy`' H L';5! yyb L 4*! ' 4 &' #"K! & 7-#"K!' 7 2'!#"K! 2#-bz@##qq-A#-qqb- 9/"!' J9#qqbC#B qqIsthereothercourtinvolvement? *^^^^y#" *#qq BD#bqq 0&y#"^^^^ 0NO 6^^^^#!y#"  6 0&y#"^^^^ 0YES 9/!y#"  9Next y#" ̀court 9$a# date(s): $!$  @j 7'&!9%a$  7@= 0&9$a#' 0@ E Judicial #!# Districtor $# Judge: 7'&!y%$  7@##L# 7-#!# J ' 7Ifyes,explain.#-bC##qq-D#-qqb- )'+'S& )   6      >     1' &%  '  1^"<vPerson(s)agreeingto (E' ̀Services: ' ('  #-bG#vH0&$(E'   '  0*d ddd dd wdd wdd wdd wdd dd dd |dd |}dd |%%,dd ,tdd ,dd ,dd ,ddd ,ddd +  #qq-G#p qq #c)(c)( I#d,j  pWhenwasFamilyPreservation )( ̀Servicesofferedtothefamily?#p  ,jK# +'*) +d#qq p{K#-qq  'E*m)' 'd,b-Whendidthefamily )( ̀acceptFamily *) Preservationservices? +'+*  +d#-,bM# 'E*m) ' 'd#qq-L#-qq,b-Whenwasthe )(  ̀family *) spokentolast?#-,bWN##qq-8N#p qq +'+* +d#qq p O#p qq@ # #J # 6,C*k) I ' 6%-),   %O*.'/ dddd tdd tdd dd ddd dddd d%%,dd , dd +  $7-_,7-_, $^*rlXX* SECTIONIIIBriefsynopsiswhythefamilyis -, ̀beingreferred: 1' [.- 1,j  p D'3!-,' D G'6$M/u.' G G'6$?0g/' G G'6$11Y0' G G'6$<d' G G'6$.V' G G'6$ H' G G'6$:' G G'6$,' G @6$' @4*(  4^cQ*'  d  ddd  dd .'/%%,dd ,,dd ,rdd ,,dd ,edd ,,dd ,dd +  ,"vv n,R  ,j Ifapplicable,givestatusofchildabuse/neglect_  ԍ  Ѐassessment #,j  RV#_____  7^^^^$" 7j  ,j 0& ^^^^ 0Processof_  ԍ   ̀Completion_  7^^^^$"   7 0& ^^^^ 0Substantiated 6^^^^#!   6 0& ^^^^ 0_UnSubstantiated_#,j  jX#6,* n  6*'d ddd ,dd ,rdd r,dd ,edd e,dd ,dd ' %%,:dd ,,dd ,dd ,,dd , dd ,,dd ,*dd +  ,''   ,j  ,jIsanymemberofthefamilyreceivingmentalhealthservices? ?'^^,!H p'' ? <'/!H p'^^ <N/A ?'^^^,!H p' ? <'/!H p'^^^ <Yes,Ifyes,completethe H p ̀following:#,j  j\#j  ,j ?'^^^,! " ' ?#qq j~O# B''/!H p'^^^ BNo 9',!H p'' 9\^#,qqqq]#qqq,q@++  Nameoffamilymember ='0! : ' =@( NameofCurrentTherapistorCaseManager >4$ : ' @> " , @ " +! ,    @+ "" J @ " &" J    @&7Wo "@h @ "#,qqqq _#^^o7W`@h    *)'+d/d:dd :,dd ,dd ,dd , dd  ,dd ,*dd *'%%,dd ,dd ,dd ,:dd ,,dd +  '** ' 3)f  3 H''''5&f!   Hlqqq,q bqqListcurrentservicesbeingprovidedthroughaClientServiceAgreementandindicateifauthorizedby_SRS_Ԁtocontinue,if ," ̀any.Iftherearenone,writein none. A'4$$'''' AlYc#,bbic#b,b@   Service 9',!%' 9@8  Provider ='0!&' =@Z!Z!E # _SRS_Ԁ_appovd_Ԉ ' Yesm$m$M+%No #,bbe#b,bԈ <'/$?(' < 2(&)  ' 2d^G  +  ' ,  '-' ' $. $^GFg#,bbf# /  *!dddd dd dd :dd :,dd ,)'+%%,7dd , dd ,Sdd ,wdd ,dd ,wdd ,,dd ,dd ,dd +  )/ K)b,bCompletedBy: %'0 % -#1' -FAXEDorEMAILED 2 ̀Date&Time: %'4 % 4'#5' 4/ 4'#!6' 4 4'#7' 4/ 4'#!8' 4#,bb j# '9' '-#!: K   -*"$d d7dd 7 dd Sdd Swdd wdd wdd w,dd ,dd dd !%%,dd ,<dd ,wdd ,dd +  -#: B-`? ,60XHXrlX?SendthefollowingformstotheProvider: 2Z; (Checkallthatapply)#,qq,bc#,bq,q .$> .0 1 01X%1X%0X%X%0X%X%09X%X%09X%9X% X%X% Ѐ(SameasReferralDate)#,qq,bn#,bq,q /^^^s@ B  / -#A^^^ -b,bCFS1000CFSFacesheet#,bbEp#Required '^^^^B ' -#C^^^^ -CFS3050BAchievementPlan(ifapplicable) '^^^^D ' -#_G^^^^ -CFS2003SafetyPlan(asappropriate) H @   * K * 6,!L 6"M  "`mA=)0|#ddE/0|#A t    0XM Distribution:1.ProviderAgency2.RegionalContractSpecialist(Noattachments)3._SRS_ԀCaseRecord#,qq,bo#0 <