Form 611 "Child Care Special Needs Form" - Delaware

Form 611 is a Delaware Health and Social Services form also known as the "Child Care Special Needs Form". The latest edition of the form was released in June 1, 2004 and is available for digital filing.

Download a PDF version of the Form 611 down below or find it on Delaware Health and Social Services Forms website.

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Download Form 611 "Child Care Special Needs Form" - Delaware

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DELAWARE HEALTH
AND SOCIAL SERVICES
DIVISION OF
SOCIAL SERVICES__________
Telephone: (302)
TO: ______________________________
DATE: _________________________
______________________________
______________________________
RE: ____________________________
____________________________
____________________________
Dear
The above named client has applied for child care services provided by this agency. As a
condition of eligibility for service, each client must present written documentation of his/her
need for the service. The form on the reverse side of this letter will be used to verify that child
care is necessary due to the indicated special need. Please complete the required information and
return it to me in the enclosed envelope.
Agency policy dictates that service may be authorized for periods less than, but never to
exceed six (6) months; consequently you may be asked to complete another form verifying the
client's need for continued service.
If during the course of your visits or appointments with the above client, you find that the
special need that required child care service has changed or no longer exists, please notify me as
soon as possible so that we can re-evaluate the client's need for service.
If you have any questions or concerns in this matter, please do not hesitate to contact me
at _______________________.
Sincerely,
Social Service Worker
cc: Client
Case Record
______________________________________________________________________________
P. O. Box 906 - New Castle, Delaware 19720
Form 611 (Rev. 6/2004)
Document No. 350701-02-10-10
DELAWARE HEALTH
AND SOCIAL SERVICES
DIVISION OF
SOCIAL SERVICES__________
Telephone: (302)
TO: ______________________________
DATE: _________________________
______________________________
______________________________
RE: ____________________________
____________________________
____________________________
Dear
The above named client has applied for child care services provided by this agency. As a
condition of eligibility for service, each client must present written documentation of his/her
need for the service. The form on the reverse side of this letter will be used to verify that child
care is necessary due to the indicated special need. Please complete the required information and
return it to me in the enclosed envelope.
Agency policy dictates that service may be authorized for periods less than, but never to
exceed six (6) months; consequently you may be asked to complete another form verifying the
client's need for continued service.
If during the course of your visits or appointments with the above client, you find that the
special need that required child care service has changed or no longer exists, please notify me as
soon as possible so that we can re-evaluate the client's need for service.
If you have any questions or concerns in this matter, please do not hesitate to contact me
at _______________________.
Sincerely,
Social Service Worker
cc: Client
Case Record
______________________________________________________________________________
P. O. Box 906 - New Castle, Delaware 19720
Form 611 (Rev. 6/2004)
Document No. 350701-02-10-10
DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION OF SOCIAL SERVICES
C
C
S
N
F
HILD
ARE
PECIAL
EEDS
ORM
Client Name:
__________________________________
Address:
__________________________________
__________________________________
Number of Children Needing Service: ________
Names of Children Needing Child Care:
_____________________________
______________________________
_____________________________
______________________________
Presenting Problem (Why child day care service is needed?):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Benefits of service (How service will benefit child. How service will help, eliminate, improve or
reduce presenting problem?):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Consequences if day care is not provided:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Duration of need for service ________ (weeks)
_________(months)
Therapy: ________ hours per day
___________ days per week
Signature: ______________________________________ Date: _______________
Title: _____________________________
Name of Agency or Practice:___________________________ Phone No.: ( _ )___________
Referring Agency: ______________________________________________________________
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