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Conflict Panel
Dependency Contact
Dependency Attorney Name
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DCFS CSW Name
Phone 2
Email 2
Referral Information
Dependency Court Case No.
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First Name
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Last Name
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Birth Date
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Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
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19
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25
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28
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30
31
Year
Gender
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Male
Female
Non-binary
Decline to state
Transgender Status
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No
Yes
Decline to state
Race/Ethnicity
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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
State/Province
Zip Code
Phone Number
Does the youth have the following characteristics? Check all that apply.
AWOL—Current
AWOL—Risk
Conservatorship
CSEC
Dual Supervision
EPY
Gang Involved
Homeless
Medical Concerns
Mental Health
NMD
PA Advocacy Areas
- AB12 Consultant
- Education
- Employment
- Housing
- Reproductive Health
Re-entry
Regional Center
Substance Abuse
Undocumented
Additional CLC Information
Is there a companion case?
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No
Yes
Name of Clients
Is there a conflict history?
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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.
Case
Case Start Date
Month
Month
Jan
Day
Day
28
Year
Year
2025
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.
Internal Case Review Notes
