Refer a Case

How did you learn about ISS USA?

Attended an ISS event
Part of ISS network
Received ISS USA newsletter
Referred by colleague

Web search
Worked with ISS USA before
Facebook
Twitter

Referred by another agency?

Other (Please Specify):

Overview of Case

DATE *

Country/State Where Service is needed. *

Multiple Choice *

New Referral
Additional service(s) for existing case

ISS-USA Case Number:

Case Name:

Person Referring the Case

Individual:
Agency (Please Specify):
Job Title:

Individual:

Agency:

Job Title:

Name: *

Address: *

City / State: *

Zip Code: *

Phone: *

Email: *

Service Requested

Services Requested

Protective Service Alert
Home Study
Post Placement Follow-Up
Child Welfare Check

Services Requested

Criminal Background Check
Child Abuse Registry Check
International Adoption
Reference Report

Services Requested

Document Tracing
Person Tracing
Child Resource Survey
Translation

Other (Please Specify):

Where is the child currently located (in which state/country)?

Are there any plans to move the child prior to the completion of the requested service? *

Yes
No

Has anyone in this case been the subject of immigration enforcement? *

Yes
No

Are there any pending court dates of which we should be aware? *

Yes
No

If yes, please list:

SECTION I: Information on Person Receiving Services

(Child or Adult) by Your Agency
Please list all individuals for whom you are requesting this service in Section A.

Section A

Client Full Name: *

Multiple Choice *

Male
Female

Date of Birth (mm/dd/yyyy): *

Citizenship (if known):

Place of Birth: *

Address: *

Phone Number: *

Email: *

Section B

Has the child been exposed to any of the following? (Check all that apply)

If "Other", Please Specify in the text field below.

Section C

Is the child currently being treated for any of the following? (Check all that apply)

Medical condition(s)
Physical Health concern(s)
Psycho-social dev. delays
Mental Health concerns
Behavioral concerns
Other

If "Other", Please Specify in the text field below.

Section D

Please list all therapeutic services and/or medications the child is currently taking related to subsection C:

Medical Condition(s) - Specify:

Physical Health concern(s) - Specify:

Delays in psycho-social development - Specify:

Mental Health concerns - Specify:

Behavioral concerns - Specify:

Other - Specify:

NOTE: ISS-USA may request additional information about the child.

If the child is presently being treated for any conditions as noted above please provide pertinent information about the child’s current medications, treatments, or therapies. If the child is not currently receiving any treatment or medication you may not be required to provide additional documentation.

Section II: Persons Involved

1. Child Information

Please include all children for whom service is needed

PLEASE NOTE THAT IF THE CHILD IS A FOREIGN OR DUAL NATIONAL YOU MUST, BY LAW, NOTIFY THE EMBASSY OF THE CHILD’S HOME COUNTRY THAT THE CHILD IS IN YOUR CARE.

Birth Date:

Gender: *

Male
Female

Name: *

Place of Birth: *

Civil Status: *

Nationality: *

Address: *

Phone Number: *

Does this child have a sibling?

Yes
No

If yes, please complete the fields that will appear below.

Is there another sibling?

Yes
No

If yes, please complete the fields that will appear below.

PERSON 1

People involved in the case in the country/state where you need services:

Birth Date: *

Name: *

Place of Birth: *

Civil Status: *

Nationality: *

Profession:

Address: *

Phone Number: *

Relationship to child(ren) in Section 2.1: *

Is there a 2nd Person? *

Yes
No

If yes, please complete the fields that will appear below.

Is there a 3rd Person? *

Yes
No

If yes, please complete the fields that will appear below.

2. Background Information

a. Chronological summary of client’s history of involvement with your agency

b. Permanency plan for the child(ren):

3. Service Requested

(Please note that you may request only one service per referral form. Additional services must be requested on an additional referral form)

Clearly outline exactly what service is needed in asked to the other country/state.

Complete the following questions ONLY if you are requesting a home study, child welfare check, post-placement check, child resource survey or a PSA:

a. Specific Areas of Concern About the Child

Clearly outline any behaviors, emotional or psychological issues, medical needs, etc. that could have an impact on the caregivers ability to care for the child in the new environment. Include needs such as counseling, physical therapy, or access to medical care.

b. Specific Areas of Concern About the Prospective Caregiver

Clearly outline any behaviors, emotional or psychological issues, medical needs, etc. from which the caregiver suffers that could have an impact on the caregiver’s ability to care for the child. Include knowledge of any past substance abuse, or history as an abuser. If none are known please note that to your knowledge there are no concerns about the prospective caregiver.

Additional Information

Attach any information that may be relevant to the request.

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