CLC1 EPY Referral Form

Referral Date

CLC Firm

Expecting and Parenting

If pregnant, has the attorney had a conversation with the youth about legal rights and options (e.g., terminate pregnancy, parent child/and/or adoption)?

Does the youth have children?

If pregnant, expecting due date

Contact Log

Dependency Attorney Name

Supervisor Name

Phone

DCFS CSW Name

Phone

DCFS SCSW Name

Phone

Contact Log

Attorney Name

Phone

Upcoming Court Dates (if known)

Do you know this young person's upcoming court dates in dependency and/or delinquency?

Next Dependency Court Date

Time

Hearing

IF DEPENDENCY HEARING

Dept. No.

Enter ONLY numbers

CLC Unit

Type of Court

Next Delinquency Court Date

Time

Hearing

IF DELINQUENCY HEARING

Dept. No.

Enter ONLY numbers

CLC Unit

Additional CLC Information

Is there an open case on youth's child?

Companion Case

What is the next court date for youth child's case?

Hearing Type

Date

Time

Dept. No. 3

Enter ONLY numbers

Please provide a short summary of youth’s issues and status of parenting case.

If waitlisted, what was the outcome of the referral?

Note: The "Waitlisted" option should only be used if the program is at max capacity. "Accept referral" if the waitlisted period is less than 30 days. If the referral date is more than 30 days, select the "New Referral" option and instruct the attorney to submit a new referral with updated information. If the attorney is no longer interested in services, select the last option.

Date Assigned to CCM for Youth Follow Up

Referral History

EPY CCM Assigned to Screen Youth

Date of Youth Contact

Referral Outcome

Indicate youth interest in the program (i.e., referral outcome)

Case Opened

Case Type

Case Status

Medium

Case Subject

Do not change data on this line.

Case Start Date

EPY Staff Assigned to Case