referral to community-based in-home services

REFERRAL SOURCE
Date of referral:	District Office:	CPS	JJS
CPSW/JPPO name:	Phone:
Email address:
Supervisor name:	Phone:
Supervisor email:

Family DEMOGRAPHICS
Target child name:	DOB:
DCYF case ID number:	Client ID number:	Gender:
Current grade:	Primary language:
Race:	Ethnicity:
Parent/guardian name:	DOB:
Phone:	Call Text	Email:
Do they have legal custody?	Yes No	Primary household?	Yes No
Address:
Relationship to target child:
Parent/guardian name:	DOB:
Phone:	Call Text	Email:
Do they have legal custody?	Yes No	Primary household?	Yes No
Address:
Relationship to target child:
Sibling(s):
Name:	DOB:	Name:	DOB:
Name:	DOB:	Name:	DOB:
Address of siblings:
Will siblings be involved in the service?	Yes No
Other household member(s):
Name:	Relationship:
Name:	Relationship:
Name:	Relationship:

SERVICE REQUEST
Crisis Referral (24 hours to respond to the family)
Title IV-E Prevention Service
Intercept	Multisystemic Therapy (MST)
Healthy Families America (HFA)*
*This is a voluntary service.
Other Community-Based Service
Adolescent Community Therapeutic (ACT)	Individual Service Option (ISO)
Child Health Support (CHS)	Lifeskills Education and Training (LifeSet)
Home-Based Therapeutic (HBT)	Therapeutic Day Treatment (TDT)
Frequency of supervised parenting time:
Days needed:	(per week)	Hours needed:	(per week)
Elements For Service/Intervention
Reason for referral:
Family strengths and needs:
What skills and/or behaviors should the family or youth be demonstrating at the end of services?
What does successful service intervention look like for this family?
Diagnoses:
Therapeutic needs:
Restricted visitiation/parenting time:
Other:

case information
Reason for DCYF Involvement
Safety and Risk Factors in the Home
Weapons Pets Drugs/paraphernalia Public health concerns Other
Restraining order / no contact order
If yes to weapons - how many, what type, how are they stored:
If yes to other, explain:

Placement	Not APPLicable
In-home	Child-specific/kinship caregiver	Foster family home	Residential
Supervised Independent Living (SIL)	Describe:
Placement provider name:	Phone:
Address:
School name:	Child care name:

PREGNANCY INFORMATION (FOR HFA ONLY)	Not APPLicable
If the person being referred to HFA is pregnant, please complete the following fields:
Is this a first Pregnancy? Yes No	Is this a high-risk pregnancy? Yes No
Due date:

INSURANCE
Insurance company:	Policy number:
Medicaid number:
Managed care number:	Managed care agency:

CASE TYPE & LEGAL INFORMATION (check all that apply)
Abuse	Neglect	B-Case	Voluntary	CHINS
Delinquency	Aftercare	HOPE Extended Foster Care	Post Adopt
Legal status:	Court:
Next hearing date:	CASA/GAL Name (if applicable):
Date of next family meeting:	Type of family meeting:
Permanency goal:	Concurrent goal:

continued dcyf involvement (If Applicable) Not Applicable
Has youth agreed to an open DCYF case after turning 18?	Yes No Not Known
If yes, what type of case?
Extended jurisdiction	HOPE Extended Foster Care	Aftercare	Voluntary
Young Adult Information
Young adult name:	Phone:
Email address:	Alternate phone:
Address:

ADDITIONAL Attached INFORMATION
The following documents are attached (if available) to assist the provider in determining whether to accept the family or child for services:
Completed assessment tools used
Child and Adolescent Needs and Strengths (CANS)
The “Prevention Plan” (Form 1549)
The “Case Plan” (Form 1550)
The “Child/Youth Information Sheet” (Form 1552)
The “Authorization for Release and Exchange of Confidential information” (Form 1541)
Dispositional Assessment Report/JJS
The “Social Study”/ CPS
Court Report and Court Orders
Safety Plan
Action Plan
Plan of Safe Care
Other: