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CLC4 YPSAC Referral Form
Referral Date
CLC Firm
- Select -
LA 1
LA 2
LA 3
LA 4
LA 5
SAC 1
SAC 2
Conflict Panel
Youth
Dependency Court Case No.
First Name
Last Name
Birth Date
Living Situation
- None -
Homeless/Unhoused
Shelter
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
DCFS Group Home
STRTP
Probation Suitable Placement
Probation Camp
Dorothy Kirby Center
Transitional Housing
Living with Self
Other
Juvenile Hall
STRTP - EPY
Away from Care/AWOL
Substance Abuse Treatment Facility
Secure Treatment Facility (SYTF)
Regional Center Home
Supervised Independent Living (SILP)
NMD not in placement
NMD not in approved SILP
Jail
Street Address
City
Postal Code
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
United States Minor Outlying Islands
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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.
Specify Caretaker Type
- None -
Biological Parent
Caregiver/Guardian
Placement Staff
Individual Name
Relationship to Youth
Phone
Gender
Male
Female
Non-binary
Decline to state
Transgender Status
- Select -
No
Yes
Decline to state
Race/Ethnicity
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
Check all that apply.
Preferred Pronouns
- None -
he/him/his
she/her/hers
they/them/their
Email
Phone Number
Other Ways to Reach Youth
If youth is living in a placement, what is the placement phone number?
Expecting and Parenting
This client is a:
- Select -
Minor EPY
NMD EPY
How many weeks along is the pregnancy?
EPY Status
- Select -
Expecting
Parent
Expecting and Parent
Child(ren) information
Please provide each child's name and DOB.
Dependency Contact Information
Dependency Attorney Name
DCFS CSW Name
Phone
Email
Upcoming Court Dates (if known)
Next Dependency Court Date
Hearing
- None -
Juris
PR
21e
21f
22
26
RPP
364
Contested
Conservatorship Hearing
NMDR
391
ROR
PRI
388
Other
Dept. No.
Additional CLC Information
Is there a companion case?
- Select -
No
Yes
Is there a conflict history?
- Select -
No
Yes
Name of Clients
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 situation and reasons why PFI services may be helpful.
If ineligible, what was the ineligibility reason?
- None -
Conflict
No longer expecting / parenting
No prevention issues
Current child welfare petition
Financial assistance only
Not housing ready
Other
No housing issue
Aging out <90 days
Youth 21
Youth approaching 21 (<90 days)
If waitlisted, why was the youth waitlisted?
- None -
CW Investigation Pending
PFI referrals at capacity
If waitlisted, what was the outcome of the referral?
- None -
Pending
Accept Referral
New Referral
Services No Longer Needed
