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CLC4 YPSAC 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
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
*
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
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
Preferred Pronouns
- None -
he/him/his
she/her/hers
they/them/their
Email
Phone Number
Other Ways to Reach Youth
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
Expecting and Parenting
This client is a:
*
- Select -
Minor EPY
NMD EPY
EPY Status
*
- Select -
Expecting
Parent
Expecting and Parent
How many weeks along is the pregnancy?
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
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
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
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 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
No housing issue
Aging out <90 days
Other
If waitlisted, why was the youth waitlisted?
- None -
CW Investigation Pending
PFI referrals at capacity
If waitlisted, what was the outcome of the referral?
Pending
Accept Referral
New Referral
Services No Longer Needed
Internal Notes
