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CLC3 EPY Referral Form
Referral Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
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12
13
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31
Year
Year
2022
2023
2024
2025
2026
Youth
Dependency Court Case No.
*
Delinquency Court Case No.
PDJ
First Name
*
Last Name
*
Birth Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Phone Number
Gender
*
- Select -
Male
Female
Non-binary
Decline to state
Transgender Status
*
- Select -
No
Yes
Decline to state
Race/Ethnicity
*
Check all that apply.
Asian
Black/African American/African
Hispanic/Latino
Middle Eastern/North African
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White/Caucasian
Client Declines to State
Client Does Not Know
Other
Unknown
Living Situation
- None -
Away from Care/AWOL
Homeless/Unhoused
Shelter
Substance Abuse Treatment Facility
Residential Treatment Center
Home with One Biological Parent
Home with Both Biological Parents
Home of Relative
Home with NREFM
Medical Hospital
Psychiatric Hospital
DDMI
DCFS Foster Home
FFA Foster Home
STRTP
STRTP - EPY
Juvenile Hall
Probation Suitable Placement
Probation Camp
Dorothy Kirby Center
Secure Treatment Facility (SYTF)
Regional Center Home
Transitional Housing
Supervised Independent Living (SILP)
NMD not in placement
NMD not in approved SILP
Jail
Other
Street Address
City
Zip Code
State
If the youth's living situation is juvenile hall, does the youth have a placement in place?
No
Yes
If yes, please describe in the notes.
If youth is living in a placement, what is the placement phone number?
Specify Caretaker Type
- None -
Biological Parent
Caregiver/Guardian
Placement Staff
Individual Name
Relationship to Youth
Phone
Expecting and Parenting
Does the youth have children?
*
- Select -
No
Expecting
Parent
Expecting and Parent
If pregnant, expecting due date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
2070
2071
2072
2073
2074
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)?
*
- Select -
No
Yes
Contact Log
Dependency Attorney Name
*
Supervisor Name
Phone
Email
DCFS CSW Name
Phone
Email
DCFS SCSW Name
Phone
Email
Contact Log
Attorney Name
Phone
Email
Upcoming Court Dates (if known)
Do you know this young person's upcoming court dates in dependency and/or delinquency?
- None -
Yes, dependency court date/time is known
Yes, delinquency court date/time is known
Yes, both dependency and delinquency court date/time is known
Next Dependency Court Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Time
Hour
Hour
1
2
3
4
5
6
7
8
9
10
11
12
:
Minute
Minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
am
pm
Hearing
- None -
Juris
PR
21e
21f
22
26
RPP
364
Contested
Conservatorship Hearing
NMDR
391
ROR
PRI
388
Other
IF DEPENDENCY HEARING
Dept. No.
Enter ONLY numbers
CLC Unit
CLC1 EPY
CLC3 EPY
CLC1 DSY
CLC2 DSY
CLC3 DSY
CLC4 DSY
CSEC
PFI
Peer Advocates
Type of Court
Dependency
Delinquency
Dependency & Delinquency
DREAM Court
Adult Criminal Court
Administrative Hearing
Next Delinquency Court Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Time
Hour
Hour
1
2
3
4
5
6
7
8
9
10
11
12
:
Minute
Minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
am
pm
Hearing
- None -
Arraignment
241.1 Hearing
Juris
PR
777
JDRV
15-Day Review
Disposition
Other
IF DELINQUENCY HEARING
Dept. No.
Enter ONLY numbers
CLC Unit
CLC1 EPY
CLC3 EPY
CLC1 DSY
CLC2 DSY
CLC3 DSY
CLC4 DSY
CSEC
PFI
Peer Advocates
Additional CLC Information
Is there an open case on youth's child?
*
- Select -
No
Yes
Companion Case
What is the next court date for youth child's case?
Hearing Type
- None -
Juris
PR
21e
21f
22
26
RPP
364
Contested
Conservatorship Hearing
NMDR
391
ROR
PRI
388
Other
Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
2070
2071
2072
2073
2074
Time
Hour
Hour
1
2
3
4
5
6
7
8
9
10
11
12
:
Minute
Minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
am
pm
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?
Pending
Accept Referral
New Referral
Services No Longer Needed
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
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2022
2023
2024
2025
2026
Referral History
EPY CCM Assigned to Screen Youth
*
- None Found -
Date of Youth Contact
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
2070
2071
2072
2073
2074
Referral Outcome
*
Pending
Accept
Youth Decline
Youth Unreachable
Other
Indicate youth interest in the program (i.e., referral outcome)
Case Opened
Case Start Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2022
2023
2024
2025
2026
Case Type
CLC4 DSY
CLC4 PA
CLC4 MHAT
CLC4 CSEC
CLC1 EPY
CLC2 DSY
CLC3 DSY
CLC4 CSEC Parent
CLC4 YPSAC
CLC4 HPA
CLC3 EPY
CLC1 DSY
Case Status
- Automatic -
Active
Urgent
Maintenance
Closed
Medium
In Person
Phone
Text
Email
Fax
Letter Mail
Case Subject
Do not change data on this line.
EPY Staff Assigned to Case
*
- None Found -
