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Child Protective Services Structured Intake Form

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North Carolina Department of Health and Human Services | Division of Social Services Child Protective Services Structured Intake Form DSS-1402 (Rev. 10/2019) Child Welfare Services Page 1 of 19 Section I: Demographics Date: _________________________ Time: _______________________ Received by (Name): ________________________ County: ______________________ Screening Decision: _________________ Referred Due to Residency: _________________ Assigned to: (County/Worker Name) ________________________________________ _______ Referred to: (County Name) ___________ Date/Time: ______________________ Confirmed with.

N/A Moral Turpitude Does the parent/caretaker encourage, direct, or approve of the child(ren) participating in illegal activities such as shoplifting, fraud, selling drugs/alcohol? If so, what activity or activities is the child(ren) participating in that the parent is

  Intake, Moral, Moral turpitude, Turpitude

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