Forms

Child Welfare Forms

4A-Imminent Risk Check List
To receive Family Preservation/Emergency Assistance (FPP/EA) (Which includes any services outlined in the Core Service Program, Colorado Works Non-Cash/Non-Monetary Services (NC/NMS), a family must meet the following Guidelines:

1. The family income must be under $75,000 yearly
2. The child lives with a specified relative within the fifth degree of kinship
3. The family has a specified need or emergency

In order for services to be delivered, each client must fill out the EA application, meet the above guidelines, and be referred to the appropriate services.

Affadavit of Citizenship - English Version

Affadavit of Citizenship - Spanish Version

Affidavit and Advisement
 

American Indian/Alaska Native Assessment Form
Used to established if a child is American Indian/Alaska Native and provide information on who should be noticed and contacted in order to comply with the Indian Child Welfare Act.

The Child Specific Addendum
This form shall be completed on a yearly basis for each child and shall specify the responsibilities of the provider and the county in the services to be delivered to the individual child and family in conjunction with the Family Services Plan.

CCAR Form
The Colorado Client Assessment Record (CCAR) is used to determine medical necessity for RTC clients, which is a requirement for placing a child/youth into a Residential Treatment Center (RTC).  CCAR's must be completed on a child/youth before admission, anytime a child/youth's mental health status changes while in placement with the RTC and then upon discharge.
 

Colorado Assessment Continuum
Safety, Risk and Needs Assessment (North Carolina Family Assessment Scale) to be used in a sequential and integrated manner for case planning and prioritization of services throughout the life of Child Protection Cases.  These instruments have all been field tested and achieved high validity and reliability ratings.

• Safety Assessment Instrument
• Safety Assessment Definitions
• Risk Assessment Instrument
• Risk Assessment Definitions

For copyright reasons, the NCFAS-R instrument and definitions can only be accessed by Colorado users on our password protected portal.

The following six documents are the Relative Guardianship Assistance Forms:

CW-RGA-2A  is the Title IV-E Addendum-it is a bridging document to add other siblings to the agreement, therefore making them Title IV-E eligible if they weren't previously

CW-RGA-4 is the Non Title IV-E Summary and Application

CWS-3 Voluntary Placement Agreement 
This form is used when a parent(s) and the  county department agree voluntarily to place a child into foster care.  This would occur in situations where there are no child protection issues (abuse or neglect). The child's treatment needs cannot be met by the family in the home.  The CWS-3 is only valid up to 90 days.

CWS-7A Individual Provider Contract for Purchase of Foster Care Services and Foster Care Facility Agreement
This form outlines the responsibilities for county department and county foster parents.  The document must be completed for each child placed in a county foster home.  The contract must be completed and signed annually by the foster parents and the county department.

CWS-10 Renewal Notice of Certificate
This form is sent to the foster home at least 90 days prior to renewal in order to allow the foster home to determine if they want to be certified.

CWS-12A Medical From for other Adults and Children in Foster/Adoptive Home RevisedMedical Form to be used during the Foster/Adoptive Home Assessment for adults and Children who live in the home.

CWS-12B General Physical Examination for Foster Care and/or Adoptive Applicant Revised Medical Form to be used for any adult who is applying to be a  foster or adoptive parent.

CWS-13 OTC Authorization  This Physician Medication Authorization is for use with prescriptive and over the counter medications.  

CWS-17 Adoption Approval Form
This form is used by the counties to approve an adoptive home.

CWS-18 Adoption Placement Agreement 
Adoptive Placement agreement, which is to be signed if, appropriate by the potential adoptive parent(s) and county representative at the time of the adoptive placement.

CWS-19 Information Sharing Acknowledgement
Information Sharing form to be completed by the county placing a child for adoption.  The form is signed by the adoptive parent(s) and county representative at the time of presentation and initialed prior to the adoption being finalized.

CWS-24 A Birth Parent's History
If appropriate county can use this form to collect background information on the birth parents.  The form with de-identified information may be given to adoptive parents at the time of the placement of a child for adoption.

CWS-25 Authorization for Health Care
This form is signed by the county director when a child goes into out-of-home care.  It provides authorization to the facility to seek routine and emergency medical and dental care.  Instruction is provided to the facility regarding notification to the county department about medical and dental services, and drug administration.

CWS-61 Application to Care for Children (updated 04/27/2009)
This is the Application for individuals to complete who are interested in providing foster care for adoption for county departments.

CW-SA 1 & 2 Child's Summary and Application for Subsidized Adoption
County Departments and individuals who are applying for an Adoption Subsidy complete and sign this form.

CW-SA 1 & 2 Child's Summary and Application for Subsidized Adoption Non IV-E
County Departments and individuals who are not IV-E eligible applying for an Adoption Subsidy complete and sign this form.

CW-SA-3A Adoption Assistance Agreement
This form is completed by the county department and individuals who will be receiving an type for Adoption Assistance (Subsidy) including Medicaid.  The form is signed by the county representative and adoptive parent(s) prior to the final decree of adoption.

CW-SA-3A Adoption Assistance Agreement Non IV-E
This form is completed by the county department and individuals that are not-IV-E eligible, who will be receiving an type for Adoption Assistance (Subsidy) including Medicaid.  The form is signed by the county representative and adoptive parent(s) prior to the final decree of adoption.
 

CW-SA-3B Adoption Assistance Agreement
This form is completed when a family wins a fair hearing and a county must enter into an adoption Assistance Program after finalization.

CW-SA-4 Subsidized Adoption Review Form
Every three years the county department reviews and updates, if appropriate, the subsidized adoption agreement.

CW-SA-4 Subsidized Adoption Review Form Non IV-E
Every three years the county department reviews and updates, if appropriate, the subsidized adoption agreement.

CW-SA-5 Child's Special Needs
This form is used to establish a child's special needs when a Child Placement Agency is requesting Adoption Assistance (Subsidy) for one of their families who are adopting.

Foster Care Certificate
Issued at certification and annually thereafter. Identify whether the certificate is for one-year, provisional, or probationary. If the certificate is provisional or probationary, a new certificate must be issued when the home is fully certified. A home may not be placed on probationary status at the time of initial certification.

Health Passport
This form is provided to foster parents and facilities in order to document each foster child's medical, dental, and therapy appointments, their practitioners' information, and medication history while the child is in the foster home or facility.  The child's educational placements are also documented.  See agency letter CW-03-33-A dated November 21, 2003.

ICAMA 6.01 Notice of Medicaid Eligibility/Case Activation
This form is used to to notify another state of a Colorado Child with a subsidized adoption who is moving to another state.  It is a request to the other stat to provide Medicaid Services.

ICAMA 6.02 Notice of Action
This is a form that is used to notify another state that Colorado has received their request to provide Medicaid for one of their children with a subsidized adoption.

ICAMA 6.03 Report in Change of Child/Family Status
This form is used when a subsidized adoption child/family status changes.  For example moving form one state to another, new address, phone number, etc.

ICPC 100A Interstate Placement Request Instructions

ICPC 100A Interstate Placement Request Form
The ICPC form 100A is are used to request approval to place a child out-of- state.

ICPC 100B Report on Child's Placement Status Instructions

ICPC Report on Child's Placement Status Form
The ICPC 100B form is used to notify the ICPC office about the status of the placement and Compact Termination.

KP-1 Kinship Care Agreement Form

This agreement is for emergency visitation up to 60 days and for emergency placements until a provisional certificate is issued for child specific or kinship placements.  This agreement provides general requirements and information.  County Departments of Human/Social Services may have additional county specific requirements.

KP-1 Kinship Care Agreement Spanish Version 

MOE Eligibility Determination Form (Cert. for Emergency Assistance) Rev 2-2008
 

This form is used to determine eligibility for Child Welfare Maintenance of Effort (MOE).

MOE Eligibility Redetermination Form
 

This form is used to do the annual Redetermination of Eligibility for Child Welfare Maintenance of Effort.

MOE/TANF 5th Degree Relationship Chart
This charts list relationships needed for MOE/TANF  Case/ Client Eligibility determination.

Notice of Rights and Remedies for Families (English Version)This form supplied by the department to local law enforcements and to parent(s) and family from whom the child is removed by court order or by law enforcement.  The notice specifies the cause of the removal of the child or children.  It contains disclosure of the availability of the conflict resolution process to persons who are the subject of a child abuse or neglect report and to parents.  For a complete description of the form, see 19-20212, C.R.S. and Volume 7,7.200.4.

Notice of Rights and Remedies for Families (Spanish Version)

SS-1A Medicaid Eligibility/Redetermination
 

This form is used by various programs.  For every child who is in Subsidized Adoption the form must be completed by the county department yearly until the subsidy is closed or discontinued.

SS-3 Authorization to Release Information

This form is used to to give authority to the county department of human services to supply information to a specific person, agency, or institution.

SS-4 Notice of Child Welfare Social Services Action
 

(You may want to print this form using the  Front and Back option if you have it on your printer.)
This form is used by various programs.  In adoption it is used to inform a family of any changes to their Adoption Assistance.

SS-9 Title IV-E Foster Care Eligibility Determination Revised 8/2006
 

This document is for initial eligibility determination for Title IV-E Foster Care.

SS-10 Title IV-E Foster Care Eligibility Redetermination Revised 8/2006

This document is for re-determination for eligibility for Title IV-E Foster Care.

SS-10 V Title IV-E Foster Care Eligibility Voluntary Placement -Determination of Continuing Eligibility Revised 8/2006
 

This document is for Ongoing Eligibility of Title IV-E for Voluntary Placements.

SS-11 Adoption Assistance Eligibility Determination

This form must be completed prior to the County negotiating an Adoption Assistance (Subsidy with a family.  It is used to determine if a child's subsidy will be IV-E (Federal/State/County) or a State and County only subsidy.

SS-21B Purchase of Service Contract

This form is used for the purchase of psychological services for evaluation of children and adults who are not eligible for Medicaid as outlined in 7.003.3.

SS-23A Agreement to Purchase
 

This form is universal and shall be completed for all children whom are placed through the facility/provider.

SS-23B Child Specific Addendum
 

This child specific addendum is to be used in conjunction with the general contract (SS23A) for all providers.

Revised: 12/10/2012