Child Protective Services Assessment Consent Form

Child Information

Child's Full Name

Date of Birth

Case Number

Parent/Guardian Information

Parent/Guardian Name

Relationship to Child

Contact Number

Consent Statement

I acknowledge that I have been informed of the purpose and nature of the assessment to be conducted by Child Protective Services. I voluntarily consent to the assessment for the child named above. I understand that the findings will be used to determine the best interests of the child.

Additional Comments

Parent/Guardian Signature

Date

CPS Worker Name

CPS Worker Signature

Date