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Get NC DSS-5238 2004-2024

E attach copy of DSS Family Strengths and Needs Assessment) Date of DSS Referral: Services : Date of DSS Finding of Substantiation or In Need of Basis of Substantiation or In Need of Services : Child s Name: Date of Birth: Male Female : Race/Ethnicity: Language, if other than English: Address: Telephone Number: Referring County Department of Social Services: DSS Contact Person Telephone: Parent/Caretaker Name: (If parent is not legal guardian, list who has legal cus.

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