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FOR INTERNAL USE ONLYServices initiated:YESNOStart Date:___30 Days to Family Intake & Referral Format of Referral:___Initial Custody Date: ___Date/Time/Location of Initial TDM: ___Copy of TDM Form attached (if TDM occurred prior to referral)Date/Time/Location of PC Hearing: ___County of Jurisdiction:___ZIP CODE of Custodian (to determine Jurisdiction): ___Court petition/affidavit attachedReferring Information:Referring Agency:___Consortium___AfterHours Phone:

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