C.H.I.N.S Referral Form

CHINS Referral Form

Acknowledgements and Child Information

Detention Disclaimer: Effective January 1, 2014, children who may be determined to be ungovernable and/or truant are now referred to as Children in Need of Services (CHINS). OCGA 15-11-415(b) also states that a Child in Need of Service CANNOT be detained as a means of punishment and/or avoidance of parental responsibilities.
Child’s Legal Name
Child's Legal Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Country

Parent / Guardian Contact Information

Parent/Guardian: Legal Name
Parent/Guardian: Legal Name
First
Last
Parent/Guardian: Primary Address (If different from above)
Parent/Guardian: Primary Address (If different from above)
City
State/Province
Zip/Postal
Country
Is DFCS involved with the family?
Does the child have any current or past delinquent charges?

Child’s School Information

Does your Child have an Individualized Educational Plan (IEP) or 504 Plan?

Reason for CHINS Assistance

Confidentiality and Disclosure Notices

Confidentiality and Disclosure of Client Information:
Confidentiality and Disclosure of Client – The Behavioral Health Unit of FCJC is a collective body with members representing court employees and other vetted external agencies including (but not limited to) Georgia Health Partners, Progress Place and Chris 180. The CHINS Unit may make referrals to the Behavioral Health Unit and also to outside agencies, community organizations and/or consulting mental health professionals as necessary.
Disclosure Notice:
As Mandatory Reporters, the law authorizes us to disclose confidential information in certain circumstances without the consent of the client or client’s authorized representative. These circumstances without the consent of the client or client’s authorized representative. These circumstances include cases in which an individual is deemed a danger to self or others or if there is suspected abuse and/or neglect.
Disclosure Notice:

Electronic Signature Agreement

By selecting the “I Accept” button, you are signing this Application electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Application. By selecting “I Accept” using any device, means or actions agree that your signature on this document (hereafter referred to as your “E-Signature”) is as valid as if you signed the document in writing.
Electronic Signature Acceptance