DSS Referral Form for Early Intervention Services (CDSA - info dhhs state nc 2026

1. Click ‘Get Form’ to open the DSS Referral Form in the editor.
2. Begin by entering the 'Date of DSS Referral' and the 'Date of DSS Finding of Substantiation or In Need of Services'. This information is crucial for timely processing.
3. Fill in the child's details, including 'Child’s Name', 'Date of Birth', and select their gender. Ensure accuracy as this information is vital for identification.
4. Provide demographic details such as 'Race/Ethnicity' and 'Language', if other than English, to help tailor services appropriately.
5. Complete the contact information fields, including address and telephone number, for both the child and parent/caretaker. If applicable, include legal guardian details.
6. Answer questions regarding any known health problems or involvement with other agencies. This helps assess the child's needs comprehensively.
7. Indicate whether the child has Medicaid/HealthChoice or other insurance options. This information is essential for service eligibility.
8. Finally, provide any additional information that may assist the Child Developmental Service Agency (CDSA) in understanding your family's situation.

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