Form Acd 1019 PDF Details

Navigating the complexities of social services can be daunting for families in need of support, making forms like the ACD 1019 essential guides in the process. The ACD 1019 form, revised in June 2002 by the New York City Administration for Children’s Services (ACS), serves as a critical referral document for accessing children’s day care services. It is thoughtfully designed to gather comprehensive data from families seeking day care support, including basic information about the child or children in need, details about the family's circumstances, and the specific type of day care services requested. The form emphasizes the importance of understanding the family's financial situation, their willingness and ability to contribute to day care costs if necessary, and their attitudes towards day care placement. It also provides space for documenting the reason day care is needed, how it will benefit the child or children, and any special considerations for the family that might affect day care placement, such as transportation limitations, physical or emotional health issues, or school-related problems. Through the ACD 1019 form, ACS requires a detailed service plan, encouraging a thorough evaluation of the family's needs and how day care can meet those needs, thereby ensuring that the referral process is both comprehensive and tailored to provide the best possible outcomes for children and their families.

QuestionAnswer
Form NameForm Acd 1019
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesKINSHIP, form 1019, GDC, nyc

Form Preview Example

ACD 1019 (FACE)

 

 

 

 

 

 

 

 

 

 

 

nyc

REV 6/02

 

 

 

 

 

 

 

 

 

 

 

ACS

 

 

 

 

 

 

 

 

 

 

 

NYC Administration for

 

 

SOCIAL SERVICES REFERRAL TO ACD

 

Children’s Services

 

 

 

 

To:

 

 

 

 

 

 

From:

 

 

Date: _____ /_____ /_____

 

 

 

 

 

 

 

 

 

 

 

Director, RA #:

 

 

 

 

 

 

Agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Boro:

 

 

 

Zip:

 

Boro:

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

Day Care Program Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Basic Data

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

First Name:

 

Maiden Name:

 

Tel:

Mother

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

Apt No.

 

Boro:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

First Name:

 

 

 

 

Tel:

Father

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

Apt No.

 

Boro:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

First Name:

 

Relationship:

 

Tel:

Applicant If

 

 

 

 

 

 

 

 

 

 

 

 

Not Parent

Street Address

 

Apt No.

 

Boro:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Children Needing Day Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LENGTH OF TIME FOR

NAME

 

SEX

BIRTH

PRIMARY

 

TYPE OF DAY CARE

 

 

WHICH DAY CARE

 

 

 

DATE

LANGUAGE

 

 

 

 

 

 

IS RECOMMENDED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

¨ GDC P/S

¨ GDC INF

¨ FDC FT

____ NO. OF MONS.

 

 

 

 

 

 

¨ GDC S/A

¨ GDC SPEC

¨ FDC PT

____ NO. OF YEARS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

¨ GDC P/S

¨ GDC INF

¨ FDC FT

____ NO. OF MONS.

 

 

 

 

 

 

¨ GDC S/A

¨ GDC SPEC

¨ FDC PT

____ NO. OF YEARS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

¨ GDC P/S

¨ GDC INF

¨ FDC FT

____ NO. OF MONS.

 

 

 

 

 

 

¨ GDC S/A

¨ GDC SPEC

¨ FDC PT

____ NO. OF YEARS

 

 

 

 

 

 

 

 

 

 

 

 

 

All Other Household Members

NAME

KINSHIP

BIRTH DATE

NAME

KINSHIP

BIRTH DATE

 

 

 

 

 

 

 

 

 

 

 

 

Other Involved Agencies

AGENCY NAME

AGENCY ADDRESS

CONTACT

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

2. Family Use of Day Care Service

a. Is family in receipt of assistance?PA ¨ Yes ¨ No HA ¨ Yes ¨ No b. If family is not receiving any form of Income Support, does family have the ability to pay day

care, if required?

 

 

 

¨ Yes

¨ No

c. If “yes” is family willing to pay such a fee?

 

 

¨ Yes

¨ No

d. Attitude of Parent/Caretaker toward placement of children in day care:

 

 

¨ Highly Favorable

¨ Favorable

¨ Indifferent

¨ Resistant

¨ Highly Resistant

e. Are there any limitations in transporting child(ren) to and from day care program? ¨ Yes

¨ No

If “yes”, describe: _______________________________________________________________

nyc

ACD 1019 (REVERSE)ACS REV 6/02

NYC Administration for

Children’s Services

3. Reason for Day Care

Explain why day care is needed and how day care will aid the family and/or child(ren). Include service plan for family and/or child(ren). If recertification, update service plan to show progress or current status and explain why day care is still needed. A SERVICE OR TREATMENT PLAN MUST BE INCLUDED WITH THIS REFERRAL. Attach any additional sheets required.

4. Current Family Social Functioning

Give any additional information that might be useful in attempting to make an appropriate day care placement for the child(ren); I . E . , specifics regarding physical or emotional health, family relationships, school problems (for school-age child(ren), etc. Attach additional sheet if necessary.

Referring Person

Name (Print):__________________________________________

Tel. No.: _________________

Signature: ____________________________________________

Date: _____ /______ /_____

 

 

Supervisor

 

 

 

Name (Print):__________________________________________

Tel. No.: _________________

Signature: __________________________________________

Date: _____ /______ /_____

 

 

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