Skip to main content
CLCCMS LA
You are here
Home
CLC4 DSY Navigation
My Case Dashboard
DSY Case Consult
CLC4 DSY 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
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
2020
2021
2022
2023
2024
2025
2026
Dependency Contact Information
Dependency Attorney Name
*
Supervisor Name
Phone
Email
DCFS CSW Name
Phone
Email
DCFS SCSW Name
Phone
Email
Delinquency Contact Information
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
Dept. No.
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
Dept. No.
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
Year
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
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
Postal Code
State/Province
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
Biological Parent
Caregiver/Guardian
Placement Staff
Individual Name
Relationship to Youth
Phone
Does the youth have children?
*
- Select -
No
Expecting
Parent
Expecting and Parent
Additional CLC Information
Is there a companion case?
*
- Select -
No
Yes
Name of Clients
Is there a conflict history?
*
- Select -
No
Yes
Conflict CLC Firms
*
CLCLA1
CLCLA2
CLCLA3
Other
Conflict Case Number
Explanation for Conflict
*
Any relationship (positive or negative) with another CLC client?
Please provide a short summary of youth’s issues and status of dependency case.
If waitlisted, what was the outcome of the referral?
Pending
Accept Referral
New Referral
Services No Longer Needed
