Free 47348.FH11 - Indiana

ASSESSMENT / AUTHORIZATION FOR FAMILY AND CHILDREN EMERGENCY SERVICES
State Form 47348 (R3 / 7-06) / CW 0013

See reverse side for instructions. 1. Name 3. Check the following as it relates to the assistance group: Household's income does not exceed 250% of poverty. Child(ren) in the household meets criteria for substantiated abuse / neglect or CHINS. Household has not received emergency assistance within the last 12 months. The child is residing in the home of parent(s) or specified relatives on the date of intervention by the local office. If all the above have been answered with a check, proceed to authorization. If all the above have not been answered with a check, prepare notice of action with reason for denial. Check below the services and the extent of those services that are necessary to eliminate the family's emergency and prevent substitute care placement or bring about reunification: 4. SERVICES AUTHORIZED: 5. SPECIFY: a. WHO WILL RECEIVE SERVICES - HOUSEHOLD OR INDIVIDUAL b. SERVICES FROM: ____________ TO ____________ Substitute care for children Clothing for children Non-medical counseling for child and/or child's household 6. Other relevant information: 2. IV-A EA case number

7. Signature of Local DCS Office Director / Designee

Date (month, day, year)

INSTRUCTIONS ASSESSMENT / AUTHORIZATION FOR FAMILY AND CHILDREN EMERGENCY SERVICES
1. List the surname of the family. 2. List the IV-A EA case number as assigned. 3. Check all boxes that apply to the family for which the application is made. Note: If the household meets all the criteria in # 3, go on to # 4. If the household does not meet all the criteria, the Notice of Action must be completed for ineligibility. 4. Check all services that will be authorized through the IV-A EA program. 5. In the space available, specify who will receive the services; i.e., whether it is the entire household or individual members. Also specify the time period for the services. 6. Other relevant information can be documented here. 7. Director or designee must sign and date here. Authorization is not complete until this signature is on this form. Authorization must take place within 30 days of the application.