Social Medical History

Social Medical History

To expedite the process, provide applicable documents at the time of referral.
Worker Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
County *
*If you will be passing this case onto another worker, please provide their contact information:
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
County
Youth Information
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Race/Ethnicity*
County*
Native American Ancestry?*
Status of TPR:
Name & Contact Information for Birth Mother
Birth Mother's Name

First NameLast Name
Birth Mother's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Mother's Email
example@example.com
Birth Mother's Phone Number
Please enter a valid phone number.
Name & Contact Information for Birth Father
Birth Father's Name

First NameLast Name
Birth Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Father's Email
example@example.com
Birth Father's Phone Number
Please enter a valid phone number.
Birth & Adoptive Sibling Information

First Names, Years of Birth & Current Locations
Birth & Adoptive Sibling Information #1
Birth & Adoptive Sibling Information #2
Birth & Adoptive Sibling Information #3
Birth & Adoptive Sibling Information #4
Birth & Adoptive Sibling Information #5
Is a Social & Medical History being requested for any of the above siblings?*
Placement History w/dates– from initial entrance into foster care, to current placement
Name & Contact Info for Current Foster Parents or Staff:
Foster Parent or Staff #1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Foster Parent or Staff #2*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Additional Information about case/youth:
Is this Pre-Adoptive Placement?*
Social & Medical Histories (SMH) are completed in 30 business days from the time the referral is accepted by EVOLVE. If you need the completed SMH in back prior to that date, please let us know. If you are not able to provide the documents listed below, please complete EVOLVE SMH ROI so they can be requested.

Applicable Documents to be sent via email at this time:
o CHIPS Petition
o Out of Home Placement Plan
o TPR Petition
o TPR Order
o Ongoing Court Reports
o Birth Certificate
o Birth Records
o Medical Records
o Immunization Records
o Dental Records
o Psychological Evaluations
o Psychiatric Evaluations
o Diagnostic Assessments
o IEP Assessments & Plans
o Report Cards & other School Progress Reports
o Any other helpful background or child specific information/documents

Upload Below or Email documents to SMH@evolveservices.org
SMH Files

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Questions, or Comments
Should be Empty:

Social Medical History

Worker Information

*If you will be passing this case onto another worker, please provide their contact information:

Youth Information

Name & Contact Information for Birth Mother

Name & Contact Information for Birth Father

Birth & Adoptive Sibling Information

Name & Contact Info for Current Foster Parents or Staff: