background shadows

NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

10-29-2015

Subchapter:

1

Forms

Issuance:

11.1

CP&P Form 11-1, Referral for Early Intervention System Services

 

PURPOSE AND USE

 

Use CP&P Form 11-1, Referral for Early Intervention System Services, to refer:

·         A child under the age of three (3) years, who is involved in either a Substantiated or an Established case of child abuse/neglect, to Early Intervention System Services, in accordance with an amendment to the Child Abuse Prevention and Treatment Act (CAPTA), as amended June, 2004. See policy, CP&P-II-C-5-1100, Statutory Requirement to Refer for Early Intervention System Services.

·         Any child under age three (3) for whom the Division has concerns regarding his or her development or ability to learn.

CP&P Form 11-1 is used by Local Office staff.

 

INSTRUCTIONS FOR COMPLETING THE FORM

 

·         Date of Referral Enter the date of referral to NJ EIS.

·         Child’s Name Enter the child’s first name, middle initial, and last name.

·         Date of Birth Enter the child’s date of birth.

·         Parent(s) Name Enter the parent(s)’s first and last name.

·         Address Enter the parent(s) current address.

·         Telephone Number Enter the parent(s)’s daytime, cellular, and evening telephone numbers.

·         Child Living With Place a check in the appropriate box to indicate with whom the child is living. If “other,” please explain. If the child is in a hospital or other medical facility, enter the name and address of the hospital/facility.

·         Caregiver Name If the child is not living with his or her parent(s), enter the caregiver’s first and last name.

·         Address Enter the caregiver’s address.

·         Telephone Number Enter the caregiver’s daytime, cellular, and evening telephone numbers.

·         Reason for Referral Place a check in the appropriate box to indicate whether the referral is in accordance with the CAPTA legislation or for another reason. If “other,” explain.

·         Attachments Place a check in the appropriate box to indicate whether a professional report or medical diagnosis is attached. If “other,” please specify the type of report attached.

·         CP&P Medicaid/Other Medicaid Number Enter child’s Medicaid number, if known. If child is not covered by Medicaid, leave blank; this will not affect evaluations.

·         Referred By Enter the CP&P Worker’s name, office name, office address, and telephone number, including extension, in the spaces provided.

Fax or send the completed form to the Regional Early Intervention Collaborative (these are the regionally based system points of entry,) serving the county where the child resides.  Fax numbers and contact information may be found at www.njreic.org.

 

DISTRIBUTION

 Original       

Early Intervention System

Copy            

Child’s CP&P case record

Copy            

CP&P Local Office Child Health Unit Nurse