Certification of Proposed Social Services Professional (SSP)

Colorado Office of the Child's Representative

When to use this form:

OCR Contract Attorneys can use this form to certify that a Social Services Professional (SSP) satisfies the OCR's qualifications for the SSP payment rate in accordance with OCR's SSP Policy.

Your Name *

Your Firm Name *

Your Colorado Attorney Registration Number *

Your E-mail *

Proposed Social Services Professional (SSP):

SSP's Full Name *

If this SSP is approved, s/he will be added to CARES. Please provide an email address for CARES which belongs to this SSP only (never used by anyone else) and is exclusive to his/her relationship with your office (e.g. jdoe@myoffice.com). This is to ensure your office's confidential CARES data remains secure.

SSP's Unique Email Address *

Confirm SSP's Email Address *

I certify that this proposed SSP satisfies the Office of the Child’s Representative’s (OCR’s) qualifications for the SSP payment rate because s/he meets the following qualifications:
(Select all that apply.) *

Specify the SSP's degree(s) not listed above: *

Specify the SSP's license(s) not listed above: *

If no License or Master's above:
This proposed SSP has at least two years of professional experience and direct involvement with children/and or families: (Select all that apply.) *

with a department of human services.

as an educator.

as a juvenile service provider (e.g., juvenile probation, Senate Bill 94, or the Department of Youth Services).

with a residential child care facility, including residential treatment facilities and group homes, in a care or therapeutic role for children or youth.

with another social services organization, non-profit organization, or other relevant service provider.

Please identify the other social services organization, non-profit organization, or other relevant service provider and how that experience was relevant to SSP work. *

Signature

Type your name and date below to further certify that you will use the proposed SSP to assist in your investigation and advocacy as as required by CJD 04-06 and as consistent with the terms of your OCR contract (including but not limited to the completion of all CBI background checks). Typed signature shall suffice as if original.

Name *

Date *

Click "Submit" to complete your request.