EARLY INTERVENTION/PUP/HOMESTEAD/PARENT AIDE AUTHORIZATION

INDICATE APPLICATION TYPE WITH A CHECK ()

EARLY INTERVENTION

COUNTY NAME

CASE NAME

(LAST)
(FIRST)
FAMILY COMPOSITION (LIST ALL PERSONS IN THE HOME):
LAST NAME
FIRST NAME
1.

2.

3.

4.

5.

6.

7.

8.

PUP

HOMESTEAD

PARENT AIDE

COUNTY CODE

CASE#:
DOB

RELATIONSHIP

COMPLETE FOR REPORTING PURPOSES:

MARITAL STATUS:
EDUCATION:
RACE:
INCOME:
CPS REASONS:
PRIOR CPS CASE:
PRIOR PLACEMENT:
LENGTH/TIME CASE
HAS BEEN OPEN:

1.Single
1. <HS
1. White
1. TANF
1. Neglect
1. No
1. No

2. Married
2. HS
2. Black
2. SSI
2. Phy. Abuse
2. Yes (reason)
2. Yes (reason)

3. Separated
4. Divorced
5. Widowed
3. OTHER.
3. Asian
4. Hispanic
5. Other
3. Employed: approximate mo. income
3. Sex Abuse
4. Emo. Abuse
5. Other
N
P
S
E
Other:
N
P
S
E
Other:

1. N/A

2. <2 mos.

3. 2-6 mos.

4. 7-12 mos.

5. >1 yr.

CASE SUMMARY (Specify indicators of risk, how services will be utilized, and how the family will maintain changer after service):

CW_ 100 Early Intervention/PUP/HOMESTEAD/PARENT Aide Authorization (Revised 09/06)

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INSTRUCTIONS:

COMPLETE THE APPROPRIATE COLUMN BASED ON APPLICATION TYPE. SEPARATE APPLICATIONS

MUST BE MADE FOR EACH PROGRAM.
PUP PROGRAM ELIGIBILITY:
HOMESTEAD PROGRAM ELIGIBILITY:
EARLY INTERVENTION/PREVENTIVE
SERVICES REFFERRAL TYPE (circle one):
A) ACTIVE SOCIAL SERVICES CASES
A) ACTIVE SOCIAL SERVICES CASE

TYPE (circle one):

TYPE (circle one):

CPS

CPS

1. SCREENED-OUT REFERRAL
2. UNSUBSTANTIATED/CLOSED CPS
INVESTIGATION

FC

ADOPTION

AND

3. SUBSTANTIATED/CLOSED CPS

B) DOCUMENTATION OF ONE OF THE

INVESTIGATION
4) RE-ASSESSED/LOW-RISK CASE
CLOSED
FOR EARLY INTERVENTION, THE
COUNTY DEPARTMENT AUTHORIZES A
MAXIMUM OF $350.00

FC

ADOPTION

AND
B) DOCUMENTATION OF ONE OF THE

FOLLOWNG (circle one):

FOLLOWING (circle one):

1. IMMINENT RISK OF PLACEMENT:

Unnecessary placement of children in
foster care in likely within 14 days
without immediate intervention.

1. IMMINENT RISK OF PLACEMENT:

Unnecessary placement of children in
foster care in likely within 14 days
without immediate intervention.

2. IMMEDIATE REUNIFICATION:PUP
services will effect the reunification of

2. IMMEDIATE REUNIFICATION:PUP
services will effect the reunification of

children from foster care within 60

days.

children from foster care within 60

days.

PARENT AIDE PROGRAM ELIGIBILITY

3. DRUG SCREENS/SUSTANCE
ABUSE ASSESSMENT ONLY

A) PARENT AIDE SERVICES (circle one):

CPS

FC

ADOPTION

PUP AUTHORIZATION AMOUNT:

PARENT AIDE AUTHORTIZATION AMOUNT:

FOR PARENT AIDE SERVICES, MAXIMUM
AMOUNT PER CASE IS $2,500.00

If placed in foster care, it is estimated that the

child(ren) would remain in foster care
approximately months.

3. HIGH RISK CASES: Case rated highrisk

HOMESTEAD AUTORIZATION AMOUNT

MAXIMUM AMOUNT PER CASE IS:

$3,500.00

The amount of PUP funds spent shall not

exceed $
(See 75% of estimated per diem cost chart for
PUP)
APPLICATION COMPLETE BY:

_____________________________________________________________
(SIGNATURE OF CASE MANAGER)

(DATE)

APPLICATION REVIEWED BY:

_____________________________________________________________
(SIGNATURE OF SUPERVISOR)

(DATE)

APPLICATION APPROVAL STATUS:

APPROVED

DENIED

_____________________________________________________________
(SIGNATURE OF APPROVING AUTHORITY)
ROUTING INSTRUCTIONS:

(DATE)

ORIGINAL REMAINS IN CASE RECORD

COPY TO LOCAL COUNTY ACCOUNTING UNIT

CW_ 100 Early Intervention/PUP/HOMESTEAD/PARENT Aide Authorization (Revised 09/06)

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