St. Clare's Homes - Referral Form

St. Clare's Homes are contracted with the NJ Division of Child Protection & Permanency (DCP&P) to provide transitional housing and comprehensive services to children with specialized medical needs.

Links to Resources to help DCP&P match a case with St. Clare's Homes:

The form below can be printed, completed, and submitted to Debra Leib via email at dleib@stclaresservices.org or fax at (973) 242-3583.  Debra can also be contacted at (908) 351-8746.

REFERRAL FORM

Date of Referral: _________________            

NAME OF CHILD: _________________________________    DOB: __________________________

DCPP Spirit #:______________________________________    Race: _________________________

MEDICAID #:______________________________________    Projected Length of Stay: 120 days

Diagnosis: ___________________________________________________________________________

___________________________________________________________________________________

LOCATION OF CHILD: □ Hospital  □ SHSP  □ Foster Home  □ Family Home □ Other ___________

Contact Person:______________________________________   Phone: __________________________
Address:____________________________________________________________________________
City/State/Zip:________________________________________________________________________

LEGAL GUARDIAN:

Name:______________________________________________________________________________
Address:____________________________________________   Phone:__________________________ City/State/Zip:________________________________________________________________________

DCP&P:

DCP&P CW:______________________________  Phone/Ext:________________ e-mail_____________

DCP&P  Supervisor:_________________________  Phone/Ext:________________ e-mail____________

CW Supervisor:  ___________________________Phone/Ext:________________ e-mail_____________

Local Office: _________________________________________________________________________
Street Address:______________________________________________________________________
City/State/Zip:________________________________________________________________________    

Law Guardian:______________________________________   Phone:__________________________
Address/City/State/Zip:_________________________________________________________________ 

PARENTS:

Mother: _____________________________________________________________________________
Address:_____________________________________________  Phone:_________________________
City/State/Zip:________________________________________________________________________

Father:______________________________________________________________________________
Address:____________________________________________  Phone:__________________________
City/State/Zip:________________________________________________________________________

VISITATION:
Participants and Schedule:  (Visitation, if appropriate for in-home visits, will be arranged in accordance  with court ordered guidelines and St. Clare’s Visitation Policy.)

Names/Relationship to client ______________________________________________________________________________            ______________________________________________________________________________ ______________________________________________________________________________

Day(s)/Time:_________________________________________________________________________

PLACEMENT GOAL:________________________________________________________________

PLACEMENT SIGNATURE: __________________________________________________________

Please forward medical information with this referral form.

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ST. CLARE’S ONLY

Date Referral Received:_______________                              Assessment Date:_____________________
□   Accepted for Placement                                                      Placement Date:______________________                        
□   Declined for Placement
Reason for not accepting referral ______________________________________________________

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