Appendix C: Forms and Tools | CWS

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A
Form Title	Additional Languages
A Guide to Gathering Information During an Investigation
Acknowledgment by Grandparent(s) or Guardian(s)	Spanish
Acknowledgment of DFCS Driving Policy for Youth in Care
Acknowledgment of Receipt of 1st Level Request for Child Protective Services Administrative Review	Spanish
Acknowledgment of Surrender of Rights	Spanish
Adoption Assistance Annual Information Update
Adoption Assistance Eligibility Letter for Youth Age 18 and Older	Spanish
Adoption Assistance for Independent Adoptions Information for Adoptive Families
Adoption Assistance Narrative
Adoption Assistance Repayment Agreement	Spanish
Adoption Assistance Treatment Professional Report
Adoption Exchange Family Registration
Adoptive Mother’s Affidavit	Spanish
Affidavit of Consent to Adoption (Affidavit 1)
Affidavit of Consent to Adoption (Affidavit 2)
Affidavit of Department Representative	Spanish
Affidavit of Disclosure For Adoption	Spanish
Affidavit Regarding Native American Heritage and Military Service	Spanish
Agreement Between Foster Parent and County DFCS	Spanish
Agreement Supplement
Amerigroup GA Families 360° DFCS Referral Form
Another Planned Permanent Living Arrangement Agreement	Spanish
Analyzing and Assessing DFCS History Tool
Asset Purchase Intent Form
Authorization by Adoptive Parent for Payment of Non-Recurring Funds Directly to a Third Party	Spanish
Authorization for Release of Information	Spanish
Authorization for Release of Information - Babies Can’t Wait (BCW)	Spanish
Authorization for Release of Information - Family Team Meeting (FTM) or Multi-Disciplinary Team (MDT) Specific	Spanish
Authorization of Psychotropic Medication for Children in Foster Care

B
Form Title	Additional Languages
Background Information for Non-State Agency Child
Bill for Services Rendered
Biological Mother’s Affidavit Identifying Biological Father of Her Unborn Child	Spanish
Birth Family Background Information for Child

C
Form Title	Additional Languages
Caregiver Child Safety Agreement	Spanish
Caregiver Child Safety Agreement - Adult Household Members	Spanish
Caregiver Feedback Survey	Spanish
Caregiver Home Inspection Safety and Compliance Checklist
Caregiver Placement Preferences
Caregiver Protective Capacity Tool
Caregiver Reference and List Form	Spanish
Case Plan Addendum
Casey Life Skills Practice Guide
Chafee ETV Grant Program Application
Checklist for Review of Adoption Petitions
Checklist to File a Petition for the Appointment of an Adult Guardian
Child Abuse Screening Request Information
Child Fatality or Near Fatality Records Request Form
Child Life History Checklist and Registration Cover Letter
Child Life History Referral Form and Documentation Checklist
Child Specific Recruitment Plan
Childcare and Parent Services (CAPS) Maximum Reimbursement Rates
Childcare and Parent Services (CAPS) Provider Published Rate Form (CAPS Form 61)
Child Protective Services Investigation Caregiver’s Guide (Brochure)	Spanish
Children 1st Screening and Referral Form
CLEAR® Address & Household Composition Verification
Commercial Sexual Exploitation of Children (CSEC) Referral Form
Common Drug Testing Topics
Commonly Abused Drugs
Components of a Client Centered Treatment Plan
Concurrent Planning Assessment Guide
Confidentiality and Privacy Standards Agreement	Spanish
Consent for State Criminal Records Check
Consent for Young Adult Support Services
Consent for Youth to Obtain Driver’s Education, Driver’s License, and/or Drive a Motorized Vehicle
Consent to Receive Targeted Case Management Services
Consular Notification Form Letter
Continuity of Operations Plan (COOP) - Appendices Index
Continuity of Operations Plan (COOP) - Template
Converting a Non-SAFE Study to the SAFE Format - Instructions
Court Transfer Review (12/36 month) Diligent Search
Courtroom Proceedings Tips for Case Managers
Creating and Using Life Books
Credit Report Request for Youth in Foster Care
Crisis Intervention Team Referral Form
Critical Actions in Managing the Permanency Case

D
Form Title	Additional Languages
Decision Guide for Sibling Separation for Foster Care Placement
Decision-Making Support Needs Information Assessment
DFCS Teaming for Efficiency & Quality in Placement Matching & Utilization Protocol

E
Form Title	Additional Languages
Education Notification Form For School Age Youth in Foster Care
Educational Stability Checklist to Assess Support Appropriateness of Educational Setting
Educational Stability Transportation Funding Request Protocol
Emergency Assistance Supportive Services Participant Agreement
Emergency Care and Supervision of Child without Court Order (Authorization)	Spanish
Emergency Care and Supervision of Child without Court Order (Termination)	Spanish
Emergency Intake Form
Encrypt Recipient Instructions
Encrypt Sender Instructions
Enhanced Relative Rate Application and Agreement	Spanish
Ensuring Educational Stability for Children in Foster Care Field Practice Guide
Ex-Parte Petition and Order Confirming Voluntary Surrender Order - Model

F
Form Title	Additional Languages
Factors Influencing Potential for Substance Abuse
Family Educational Rights and Privacy Act (FERPA) Consent Form	Spanish
Family Evaluation Family Approval and Adoption Registration Cover Letter
Family Evaluation Family Approval and Adoption Registration Cover Letter - Instructions
Family Functioning Assessment Tool
Family Support Services Caregiver’s Guide (Brochure)	Spanish
Family Team Meeting Attendance and Confidentiality Agreement
Family Team Meeting Referral Form
Family Visitation Services SafeCare and Family Fusion Initial Referral Form
Financial Statement for Resource Parenting	Spanish
Foster Care Exit Documents Checklist
Foster Care Individual Child Medication Log
Foster Care Verification Letter
Foster, Adoptive & Kinship Caregiver Re-evaluation Instructions - Adult Household Member	Spanish
Foster, Adoptive & Kinship Caregiver Re-evaluation Instructions - Caregiver(s)	Spanish
Foster Parent Affidavit for Consideration of Adopting Foster Child(ren) Currently in Home	Spanish
Foster Parent Bill of Rights (Brochure)
Foster Parent Grievance Notification - County Director	Spanish
Foster Parent Grievance Notification - State Division Director	Spanish
Foster Parent Grievance Notification - State Mediation Committee	Spanish
Foster Parent Manual
Foster Parent(s) Notification of Decision Regarding Interest in Adopting Foster Child(ren)	Spanish

G
Form Title	Additional Languages
Genogram Symbol Sheet
Georgia Advance Directive for Health Care
Georgia Assessment of Case Plan Progress and Goal Achievement Tool
Georgia Independent Living Program Notice of Right to a Fair Hearing
Georgia Youth Opportunities Initiative Application
Gift Card Log
Graduated Independence Plan
Guide for Kinship Caregivers Supports
Guide for Secure Information Sharing
Guide for Secure Information Sharing with the Military
Guide to Child Protective Services Administrative Review	Spanish
Guidelines for Psychotropic Medications Use on Children in Foster Care

H
Form Title	Additional Languages
Head Start/Pre-K Referral Form
HIPAA Desk Reference
HIPAA Flow Chart
Human Trafficking Case Management Statewide Protocol

I
Form Title	Additional Languages
ILP After Event Review Form
ILP Event Purchase Request Form
ILP Event Sign-In Sheet
ILP Incentive Log
ILP Inventory Asset Log
ILP Transition Packet 2011 (2nd Edition)
Impending Danger Safety Threat Assessment Concepts and Definitions
Indian Child Welfare Act Notification to Secretary of the Interior
Indian Child Welfare Act Notification to Tribe Leader
Individual Volunteer Application
Individualized Assessment Tool for Prospective & Existing Caregivers
Infant Safe to Sleep Guidelines and Protocol
Institutional Placement Agreement
Intake Introduction Script
Interstate Compact on the Placement of Children (ICPC) Border Agreement: Georgia - Alabama
Interstate Compact on the Placement of Children (ICPC) Border Agreement: Georgia - Florida
Interstate Compact on the Placement of Children (ICPC) Border Agreement: Georgia - South Carolina
Interstate Compact on the Placement of Children (ICPC) Border Agreement: Georgia - Tennessee
Interstate Compact on the Placement of Children (ICPC) Financial and Medical Plan
Interstate Compact on the Placement of Children (ICPC) Financial and Medical Plan - Instructions
Interstate Compact on the Placement of Children (ICPC) Sending State Priority Home Study Request (ICPC Form 101)
Interstate Compact on the Placement of Children (ICPC) Sending State Priority Home Study Request - Instructions (ICPC Form 101I)
Interstate Compact Placement Request (ICPC-100A)
Interstate Compact Placement Request- Instructions (ICPC 100A-I)
Interstate Compact Report on Child’s Placement Status (ICPC-100B)
Interstate Compact Report of Child Placement Status - Instructions (ICPC-100B-I)
Interstate Travel Expense - Waiver
Intimate Partner Violence (Domestic Violence) Guidelines & Protocol
It’s My Turn Now Georgia Descriptive Summary
IV-E Application for Adoption Assistance Non DFCS Adoption

K
Form Title	Additional Languages
Know Your Rights - Rights for Individuals on Medication-Assisted Treatment

L
Form Title	Additional Languages
Lack of Supervision Reference Guide
Law Enforcement History Declaration
Legal Mother’s Affidavit	Spanish
Legal Services Request/Report
Live Scan Application Form
Local Interagency Planning Teams (LIPT) Handbook

M
Form Title	Additional Languages
Maltreatment Allegations & Track Assignment Quick Reference Guide
Maltreatment Codes
Mandated Reporter Letter
Medical Evaluation Report - Additional Household Member
Medical Evaluation Report - Caregiver Update
Medical Evaluation Report - Prospective Caregiver
Mental Health Questionnaire
Motivation through Stages of Change
Motivational Interviewing Overview and Tips

N
Form Title	Additional Languages
Name of Child Following Adoption	Spanish
Non-Objection to Subsequent Release of Information by Primary Sources
Non-Selection Letter
Non-Traditional Education Approval Form for School Age Youth in Foster Care Within Georgia
Notice of Annual (12 Month) Subsidy Review	Spanish
Notice of Case Record Information Available to Parents/Guardians	Spanish
Notice of Change of Placement
Notice to Caregiver (Template)
Notice to Opt-Out or Terminate Extended Foster Care
Notice of Privacy Practices	Spanish
Notice to Revoke Surrender of Rights Final Release for Adoption	Spanish
Notice of Six-Month Subsidy Review	Spanish
Notification Form for Denial, Reduction or Termination of a Service or Inter-Jurisdictional Adoption
Notification of Child Interview	Spanish
Notification of Child Protective Services Family Preservation Services Case Closure	Spanish
Notification of Child Protective Services Family Support Services Case Closure	Spanish
Notification of Child Protective Services Investigation Outcome to a Minor	Spanish
Notification of Child Protective Services Investigation Outcome to Oversight Authority, Agency, Facility, or School
Notification of Decision Related to Adoption Assistance	Spanish
Notification of In-Person Child Protective Services Administrative Review	Spanish
Notification of Receipt - Step One Grievance	Spanish
Notification of Receipt - Step Two Grievance	Spanish
Notification to Foster Parent(s) of Filing of Petition to Terminate Parental Rights	Spanish
National Youth in Transition Database (NYTD) Contact Form

O
Form Title	Additional Languages
Office of State Administrative Hearings (OSAH) Form 1

P
Form Title	Additional Languages
Parent/Caregiver – Teen Driving Agreement
Permanency Timeline	Spanish
Personal Network Matrix
Placement Agreement (Sibling)	Spanish
Placement Agreement (Single Child)	Spanish
Placement of a Waiting List Child
Plan of Safe Care
Policy Violation and Corrective Action Plan Facts
Post Adoption Services Adoption Assistance Benefits Handout	Spanish
Post-Secondary Financial Assistance Agreement
Principles of Drug Addiction Treatment
Pros and Cons of Different Specimen Sources
Prospective Caregiver Application & Instructions	Spanish
Prospective Caregiver Onboarding Pathway - Adult Household Member Packet	Spanish
Prospective Caregiver Onboarding Pathway – Prospective Caregiver(s) Packet	Spanish
Psychotropic Medication Management - Consent Process Flow
Psychotropic Medication Usage Parameters for Foster Children
Purchase of Adoption Service Agreement (Placement of a DHS Child In an Out-of-state Adoptive Home)

R
Form Title	Additional Languages
Reasons for Fostering Checklist
Regional ADA/Section 504 Coordinators Director
Relative Care Subsidy Renewal Application and Agreement	Spanish
Removal Home Income and Asset Checklist - Non DFCS Adoption
Request for 1st Level Child Protective Services Administrative Review	Spanish
Request for 2nd Level Child Protective Services Administrative Review	Spanish
Request for Adoption Assistance - Private Non DFCS-Involved Adoption	Spanish
Request for Assistance in Completing Court Review of Child placed in the Temp Custody of Relative, Non-Relative Out-of-State Custodian or Agency Until the Age of 18
Request for Fair Hearing
Responding to Caregiver Resistance
Response to Request for Assistance in Completing Court Review
Rights and Responsibilities of Youth in Foster Care
Room, Board and Watchful Oversight Placement Agreement

S
Form Title	Additional Languages
Safety and Quality Standards Acknowledgment	Spanish
Safety Barriers Guidelines for Residential Pools
Safety Plan	Spanish
Safety Plan Support Person Agreement	Spanish
Safety Roundtable Outcomes and Values
Safety Roundtable Six Phase Process
Safety Threats
Scattered Site Placement Readiness Action Plan
Scattered Site Placement Readiness Assessment for Participation in Extended Foster Care
Selection Letter
Self-Help, Peer Support and Consumer Groups
Solution Focused-Family Team Meeting Pocket Guide
Special Services Approval Notice
Special Services Denial Notice
Special Services Request Form
Statement of Case Manager Potential Placement Party Under Interstate Compact on the Placement of Children (ICPC) Regulations 2 (Regular)
Statement of Case Manager Potential Placement Party Under Interstate Compact on the Placement of Children (ICPC) Regulations 7 (Expedited)
Statement of Confidentiality
Subsidized Guardianship/Non-Relative Subsidized Guardianship Application and Agreement	Spanish
Subsidy Recoupment/Repayment Agreement	Spanish
Subsidy Review	Spanish
Summary of the HIPAA Privacy Rule
Surrender of Rights Final Release for Adoption (Biological Not Legal Father)	Spanish
Surrender of Rights Final Release for Adoption (Legal Parent)	Spanish

T
Form Title	Additional Languages
Targeted Case Management (TCM) Review Guide Permanency and Family Preservation Services
Termination Packet
The Effects of Substance Abuse on Behavior and Parenting
Transitional Living Program Youth Responsibilities
Transitional Living Supportive Services Application
Transitional Living Supportive Services Program Agreement
Transitional Living Program DFCS/Independent Living Specialist Responsibilities

U
Form Title	Additional Languages
Universal Application
United States Postal Service Address Information Request
Unreimbursed In-Home or Out-of-Home Substitute Caregivers	Spanish

V
Form Title	Additional Languages
Verification of Foster Care/Extended Foster Care Status for State Identification
Verification of Receipt of Information Packet Regarding Post Adoption Services/Adoption Assistance Benefits	Spanish
Viewing Family Systems
Voluntary Placement Agreement for Extended Foster Care
Voluntary Placement Agreement to Place Child In Foster Care (Authorization)	Spanish
Voluntary Placement Agreement to Place Child In Foster Care (Termination)	Spanish

W
Form Title	Additional Languages
W-9
Waiver of Fair Hearing
When Your Child is Placed into Foster Care - What You Need to Know as the Child’s Caregiver (Brochure)
Women Treatment and Recovery Services Providers
WTRF/RFW Referral & Confirmation of Appointment of Substance Abuse Disorder Assessment Form

Y
Form Title	Additional Languages
Youth Acknowledgment of Credit Report Receipt
Youth Runaway Prevention Plan