Therapeutic Intervention, Education & Skills (TIES)

Note: This shortened referral form is being provided at the request of various DCS staff. Please do not let the form become an obstacle to making a referral. You can still make a referral anytime by calling 931-247-1432. If you prefer to complete this form, please email it to Rachelle Summerhill at Rachelle.Summerhill@centerstone.org. You will then receive a return phone call after initial review. We will need to gather additional data before making contact with the family. If you have not received a call within 24 hours of making a referral, please call Rachelle Summerhill at 931-247-1432.

Referral Source Info:

Centerstone TIES Referral Date:*

Referral Name*

Referral Phone*

Referral Email*

Is there a child at risk of removal due to parental or caregiver substance abuse or is a child being reunified and the removal was due to parental or caregiver substance abuse?*

Yes
No

Is the family able to participate 8 - 10 hours per week for 6 weeks?*

Yes
No

Is the family able to begin services in 72 hours?*

Yes
No

Have TIES services been discussed with the family?*

Yes
No

Is at least one parent/caregiver or the child at risk willing to try TIES?*

Yes
No

If Yes, who?*

(e.g. mother, father, child at risk, caregiver)

Child at risk of removal from the home or being reunified:

(If more than one child, please provide info for the youngest or most at risk child related to safety)

Name of Child*

Child Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

County*

Phone*

Parent/Caregiver Name*

Parent/Caregiver Relationship*

Parent/Caregiver Date of Birth*

Phone*

Email

Address*

Street Address Address Line 2 City State ZIP Code

Names/Ages of Other Children in the Home

Child TFACTS #*

Date of Most Recent Face-to-Face Contact

What are the current crises putting the child(ren) at risk of out of home placement? Please describe the situation prompting removal and/or reunification:*

Has any infant/child in the home been diagnosed with NAS?*

Neonatal Abstinence Syndrome (NAS) is a group of problems that occur in a newborn who was exposed to addictive opiate drugs while the mother was pregnant (in utero).

Yes
No

Is there evidence that an infant/child in the home was exposed to other drugs while in utero?*

Yes
No

Name

This field is for validation purposes and should be left unchanged.

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Therapeutic Intervention, Education & Skills (TIES)

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