Forms

Please tell us if you need assistance because you do not speak English or have a disability. Free language assistance and/or other aids and services are available upon request. To receive free interpreter services, call 866-719-0141 or ask at the DSS local office. After the recorded message, you will reach an operator who can provide you with an interpreter. If you have a disability and need communication assistance, call 866-719-0141 or TTY: 711.
Title Effective Date
DSS-5209: Health Summary Form - Well-Visit Jun 03, 2016 03:05 PM
DSS-5211: Special Children's Adoption Incentive Fund - Request for Payment Jun 03, 2016 03:05 PM
DSS-5212: Supplemental Adoption Assistance Agreement Jun 03, 2016 03:05 PM
DSS-5213: Verification of Child's Need for Daily Supervision Jun 03, 2016 03:10 PM
DSS-5214: Agency Verification of Legal Custody and Child's Living Arrangement for Past Six Months Jun 03, 2016 03:10 PM
DSS-5215: Verification of Child's Health Condition Jun 03, 2016 03:10 PM
DSS-5217: Request for Reimbursement Of Links Special Funds Jun 03, 2016 03:10 PM
DSS-5218: Consent to Release of Identifying Information Jun 03, 2016 03:15 PM
DSS-5219: Certificate of Delivery of Preplacement Assessment Jun 03, 2016 03:15 PM
DSS-5225: Request for NC KIDS Legal Risk Search Mar 15, 2017 03:20 PM
DSS-5226: NC SDM Family Risk ReAssessment Jun 03, 2016 03:20 PM
DSS-5227: NC SDM Family Reunification Assessment Jun 03, 2016 03:20 PM
DSS-5229: North Carolina Family Assessment of Strengths and Needs Apr 30, 2019 03:20 PM
DSS-5230: NC SDM Family Risk Assessment of Child Abuse/Neglect Jun 03, 2016 03:25 PM
DSS-5231: North Carolina Safety Assessment Mar 06, 2017 03:25 PM
DSS-5231ins: North Carolina Safety Assessment Instructions Jan 01, 2017 03:25 PM
DSS-5233: Personalized Domestic Violence Safety Plan Jun 03, 2016 03:25 PM
DSS-5234: Domestic Violence Perpetrator Assessment Tool Jun 03, 2016 03:30 PM
DSS-5235 - Non-Offending Parent/Adult Victim Domestic Violence Assessment Tool Jun 03, 2016 05:15 PM
DSS-5236: North Carolina Monthly In-Home Contact Record Nov 25, 2019 10:00 AM
DSS-5236ins - North Carolina Monthly In-Home Contact Record Instructions Nov 25, 2019 10:05 AM
DSS-5236ins: North Carolina Monthly In-Home Contact Record Instructions Nov 25, 2019 10:35 AM
DSS-5237: Children’s Domestic Violence Assessment Tool Jun 03, 2016 07:45 AM
DSS-5238: DSS Referral Form for Early Intervention Services (CDSA) Dec 04, 2019 04:20 PM
DSS-5239: In Home Family Services Agreement Feb 18, 2020 10:00 AM
DSS-5239ins: In-Home family Services Agreement Completion Instructions Feb 18, 2020 10:05 AM
DSS-5240: Permanency Planning Family Services Agreement Dec 16, 2019 04:55 PM
DSS-5240ins: Permanency Planning Family Services Agreement Instructions Dec 12, 2019 10:05 AM
DSS-5241: Permanency Planning Review Dec 23, 2019 12:30 PM
DSS-5241ins: Permanency Planning Review Instructions Dec 12, 2019 10:05 AM