Neglect MDT Direct Referral

Date of Referral *

Date

Referred By: *

First NameLast Name

Agency Making Referral:

DFPS, other community partner or agency, etc.

Phone Number*

Email*

example@example.com

Primary Caregiver's Name:*

First NameLast Name

Date of Birth: *

Date

Primary Language: *

Caregiver's Phone Number*

Please enter a valid phone number.

Caregiver's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide information for any other guardian(s) or caregiver(s): (if applicable)

Please include full name, birthdate, and phone number

Oldest Child:*

First NameLast Name

Date of Birth:*

Date

Please enter names and birthdays for all children under the age of 18 in the home. *

Provide Full Name and Date of Birth if known

Schools attended (for all children):*

Please provide a brief history of the family and their involvement with services*

To include previous CPS history, involvement with community agencies/ programs, current risk factors that need to be addressed, etc.

Further resources/ referrals /support needed (please provide any information that will be helpful in connecting the family to the proper services- including insurance information if applicable):*

DFPS Case Number: *

Allegation(s):*

Disposition:

Does this Family Have Previous History With DFPS*

YesNo

To Upload a file:

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Consent to Participate:

I, being eighteen years or older, do for myself and on behalf of my minor child(ren), consent to myself and my child(ren) to receive services and case management/ tracking from the Ector County Specialized Multi- Disciplinary Team. This is an MDT comprised of various agencies that collaborate to provide specialized services and case review for children and families that have been or are currently involved with the Department of Family and Protective Services due to investigations of child abuse and/or neglect.

The following agencies are currently members of this Specialized Multi- Disciplinary Team:

Harmony Home Children's Advocacy Center
Communities in Schools Permian Basin
Safe Place of the Permian basin

Odessa Links

Methodist Children's Home
Crisis Center of West Texas
ECISD
Permiacare
First Five Permian Basin
Boys and Girls Club
Pride Center of West Texas
West Texas Opportunities, Inc.
Medical Center Hospital

I understand that:

I may be asked to sign an individual partner agency's consent for services form, aside from this consent form.
I agree that my information may be released to any member of the Specialized MDT for discussion and/ or referral.
The information shared, as it relates to my case, is confidential between the member agencies of the Specialized MDT and may not be shared with non- MDT agencies, unless allowed by law.
Specialized MDT member agencies must immediately report new or further suspicion of child abuse, neglect, or exploitation of any child, in accordance with Texas Family Code Chapter 261.101.
Once I consent to participation in the Specialized MDT, on behalf of myself and my chil(ren), we may continue to receive services and case management/ tracking until my youngest child turns 18, as deemed appropriate by the Specialized MDT, or until I terminate participation.
This consent form is valid for any additional Specialized MDT partner that may join at a later date from when this consent was signed.

· I have read the entire contents of this document. I have asked questions about this document or about any part that I did not fully understand, and I have received an explanation to my satisfaction.

Caregiver Signature

Referral for Specialized MDT Review

Client Information

For DFPS Use:

Consent Form: