DFCS Assessment / Evaluation Request Form

Welcome to the EFS Referral Form for DFCS Case Managers!

This form is intended exclusively for DFCS case managers seeking evaluations and testing services through our agency. Once submitted, EFS will contact the guardian to schedule the assessment.
DFCS / Case Manager Information
DFCS County*
Other DFCS (please specify):
Case Name*
Case Manager's Name*
Case Manager's Phone Number*
Format: (000) 000-0000.
Case Manager's Email*
example@example.com
Supervisor's Name*
Supervisor's Phone Number*
Format: (000) 000-0000.
Supervisor's Email*
example@example.com
Receive Updates – I would like updates when the assessment is scheduled and when it is completed.Minimal Contact – Unless there is an issue or delay, please only reach out when the report is finalized.
PhoneEmail

Welcome to the EFS Referral Form for DFCS Case Managers

This form is intended exclusively for DFCS case managers seeking evaluations and testing services through our agency. Once submitted, EFS will contact the guardian to schedule the assessment.
Individual – This referral is for one person.Sibling Group – This referral is for a group of siblings who are all in the same household.
YesNo
Please specify the total number of children in the sibling group.

Welcome to the EFS Referral Form for DFCS Case Managers!