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Case Information
Case Type
*
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Child/Family Focused Case
Programmatic Case
Targeted Case (Deprecated DO NOT USE)
Child Initials
*
Program Name
*
Referral Source
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Provider
Resource Center Staff
Social Emotional Consultant
Substance Abuse Prevention Specialist
Other (eg. Teacher, Guardian, etc.)
Other Referral Source
*
County/Program ID
*
Consultant ID
*
Child Care Provider ID
*
Child ID
*
Insurance Information
Does the child have Medicaid/MiChild coverage?
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Yes
No
Unknown
Demographic Information
Age (in months) at Pre-assessment
*
Gender
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Female
Male
Race
*
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African American
American Indian/Alaska Native
Asian
Native Hawaiian/Pacific Islander
White
Of Hispanic or Latino descent
Multiracial/Biracial
Other
Unknown
Refused Identification
Ethnicity
*
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Hispanic or Latino
Not Hispanic or Latino
Step Complete
Form Status
Case Status
Opened
Closed Complete
Closed Incomplete
Additional Information
Step Complete
Case Status
Active
Closed - Complete
Closed - Transitioned
Closed - Early Exit
Closed - Incomplete (DEPRECATED - please select Complete, Transitioned or Early Exit)
Case Notes
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