DFCS Assessment / Evaluation Request Form

DFCS / Case Manager Information
Welcome to the EFS Referral Form for DFCS Case Managers!

This form is intended exclusively for DFCS case managers requesting psychological evaluations and testing services only.

Once submitted, Eastchester Family Services will contact the child’s guardian to schedule the assessment.

This form is not for therapy services. If ongoing behavioral health support is needed (including therapy and/or psychiatric services), please complete the referral form for the Eastchester Family Services Behavioral Health Program instead. Please note that medication management is only offered in conjunction with therapy.
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.

DFCS / Case Manager Information