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CSEC DCFS Reporting Form
CLC Firm
- Select -
1
2
3
4
5
Client
Court Case No.
Client Full Name
Gender
- Select -
Male
Female
Non-binary
Decline to state
Race
American Indian/Alaskan Native
Asian
Black/African American/African
Hispanic/Latino
Middle Eastern/North African
Native Hawaiian/Pacific Islander
White/Caucasian
Client Declines to State
Other
Check all that apply.
Other Race
Youth's Living Situation
Away from Care
Homeless/Unhoused
Shelter
Substance Abuse Treatment Facility
Residential Treatment Center (RTC)
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
**Note: Homeless/unhoused option for NMD youth that are unhoused. NMD not in placement are NOT away from care/awol.
If “SILP”, where is the youth residing?
- None -
Home of parent
Home of relative
NREFM
Partner
Self
Other
If other SILP type, specify
Does the youth pay rent?
- None -
No
Yes
How much do youth pay for rent?
Is youth an NMD client?
- Select -
No
Yes
If NMD, are the youth’s living arrangements stable?
- Select -
N/A - NMD not in placement
No, unsafe
No, unstable
Yes, stable
Housing Tentative Definitions
Safe & Stable Housing
: maintaining a lease, sublease, or occupancy agreement in their name for 90 or more consecutive days. This includes verbal and roommate agreements with relatives, parents, NREFMs, and/or partners.
Unstable Housing
: challenges paying rent, overcrowding, moving frequently, and spending the bulk of income on housing.
Unsafe Housing
: frequent evictions, unsafe neighborhood (afraid to leave the home), home in physical disrepair, the home requires adaptive equipment to be functionally safe, domestic violence, unsafe roommate, landlord conflicts, physical conflicts with staff, neighbors and/or housemates.
If NMD, has the youth experienced homeless this reporting period?
- Select -
No
Yes
NMD Unhoused
How many days has the NDM client been unhoused this period?
Was the NMD client offered SILP?
- Select -
No
Yes, but declined
Yes, but denied
Yes, pending
Yes, grievance filed
Yes
What housing support outside of CLC services is the NMD client receiving?
None
THPs
Emergency Renters Assistance
Stay Housed LA (eviction defense)
Shelters
Emergency Housing Vouchers
Affordable Housing Programs (Section 8)
Other
Has the youth been referred to CLC Housing Team?
- Select -
No
Yes, housing case management support
Yes, Benefits Assistance Only
Yes, both housing case management & benefits assistance
Education
Is the youth enrolled in school?
- Select -
Not enrolled, but graduated
Not enrolled
Enrolled-ES
Enrolled-MS
Enrolled-HS
Enrolled-GED
Enrolled-College
Unknown
Not enrolled or unknown, specify reason
How would you characterize the youth’s school attendance?
- Select -
Consistent
Sporadic
Improved
Decreased
What are the youth’s current grades?
- Select -
Doing Well-Mostly As and/or Bs
Doing Average-mostly Cs
Doing Poorly-mostly Ds and/or Fs
Grades range low and high
Insufficient work to earn a grade/credit
Progress unknown
If progress is unknown specify the reason.
Is the youth receiving tutoring services?
- Select -
N/A - Not needed
No, youth declined
Yes, referred
Yes
Has the youth been suspended or expelled during this reporting period?
No
Yes, suspended
Yes, expelled
Has the youth received any of the following educational support services this reporting period?
No
Pending-IEP
Pending-AB167/216
IEP
AB216/167
504
Individualized Health Plan-IHP
SSPT
Other
If other educational support, specify
Have you participated in educational advocacy activities to support clients during this reporting period?
No
IEP advocacy
IEP Meeting
AB167/216 advocacy
SSPT meeting
Contacted school counselor
Conducted credit/unit check
Support with enrollment
School change support
School discipline support
Support with financial aid
Other
If other educational advocacy, specify
Mental Health
Does the youth need mental health services?
- Select -
No
Yes
What type of mental health services did the youth receive this reporting period?
None
Individual therapy
Family/conjoint counseling
IFCCS
Wraparound
Group therapy
Psychotropic medication
Full Service Partnership (FSP)
Involuntary 5150/5585 for a MH hold
Other
Other mental health services
Please indicate why mental health services are needed but youth is not receiving services.
Youth declined
Youth away from placement
Youth is looking for a provider
Other
Specify other reason
Substance Use
Does the youth have a substance use issue?
- Select -
No
Yes
Unknown
What type of substance use services did the youth receive this reporting period?
None
Counseling
Support group
Medication-assisted treatment
Inpatient substance abuse treatment
Involuntary 5150/5585 for a SA hold
Other
Other substance use services
Please indicate why substance use services are needed but youth is not receiving services.
Youth declined
Youth away from placement
Youth is looking for a provider
Other
Specify other reason
Employment
Is the youth employed during this reporting period?
- Select -
No
Yes-part time
Yes-full time
Is the youth enrolled in a job readiness program or workforce internship during this reporting period?
- Select -
No
Yes-Internship
Yes vocational training program (e.g., Job Corps)
Stability and Life Skills
How many times has the youth left without permission (AWOL) in this reporting period?
Note: Left without permission is someone who is away from care and under 18 years old. For NMD clients who left, please enter 0.
How many days in total has the youth been left without permission (AWOL’d) this reporting period?
How many replacements occurred during this reporting period?
What are the youth’s strengths?
None
AWOLs reduce
Engaged in treatment
Improved attendance
Improved behavior in placement
Improved behavior in school
Improved grades
Increased child development knowledge
Parenting Skills
Self-Advocacy
Sobriety/recovery
Talents
Other
If other strengths, specify
Does the youth have an ILP coordinator?
- Select -
No
Yes
Has the youth participated in the following stability meetings or reviewed the transition plans this reporting period?
None
90-Day Transition Plan
CFTs
ILP Aftercare Meetings
Stability Meeting
TILP
Transition Conference
Other
If other stability meetings, specify
Dual Status
Does the youth have a juvenile justice petition?
No
Yes, pending
Yes, pending competency
Yes, diversion
Yes, informal probation
Yes, formal probation
Does the youth have a criminal justice petition?
- Select -
No
Yes
Is the youth in STAR Court?
- Select -
No
Yes
Developmental Functioning
Has the youth been diagnosed with a developmental disability?
- Select -
No, and no DD suspected
No, but DD suspected
No, youth declined assessment
Pending Assessment
Yes, Intellectual disability
Yes, Autism Spectrum Disorder
Yes, Cerebral Palsy
Yes, Epilepsy
Other
Is the youth a Regional Center client?
- Select -
No
Pending assessment
Yes
If RC client, which RC currently serves the client?
- None -
East Los Angeles
Frank D. Letterman
Harbor
North Los Angeles County
San Gabriel/Pomona
South Central
Westside Regional
Other
If other, which RC currently serves the client?
If RC client, has client's case transferred between RCs during the past quarter?
No
East Los Angeles
Frank D. Letterman
Harbor
North Los Angeles County
San Gabriel/Pomona
South Central
Westside Regional
Other
If other, which RCs has the youth been transferred from?
If the youth is a Regional Center client, what services are they receiving?
None
Behavior Training
Community Integration Services
Competency Training
Crisis Intervention Services
Independent Living Skills Training
Parenting Support
Personal Attendant/Supervision (1:1)
RC Placement
Respite
Social Skills Training
Supportive Living Services
Work Service Programs
Other RC Services
Expecting and Parenting
Is the youth expecting or parenting?
No
Yes, expecting
Yes, parenting
Yes, pregnant and parenting
How many months along is the pregnancy?
How many children does the youth have?
Do the children have DCFS/child welfare involvement?
- None -
No
Pending referral
Yes, active investigation
Yes, VFM
Yes, petition filed
Yes, FR
Yes, referral generated & investigated/evaluated out and closed
If youth is pending an investigation or petition filed, where is the child placed?
- None -
HOP
HOP - other parent
Relative caregiver
Foster home
If expecting/parenting, select the services youth received during the reporting period.
None
DCFS EPY Unit/EPY Conferences
Doula
Emergency Child Care Bridge Program
Expecting and Parenting Payment
Infant Supplement Payment
Nurse Family Partnership/Nurse Home Visits
Parenting Support Payment
Reproductive Health Services/Contraceptives/Birth Control
WIC Benefits
Sexual Reproductive and Sexual Health
Is the youth currently using contraceptives and/or birth control?
- Select -
N/A - currently pregnant
N/A - youth reports no sexual activity
No, in process of obtaining birth control
No
Yes, condoms
Yes, dental dams
Yes, birth control other than LARC
Yes, LARC
Youth not open to disclosing
Unknown
Has the youth received reproductive health counseling from a certified reproductive health specialist?
- Select -
N/A - pregnant/expecting
No
No, youth declined
Yes, ACT Clinic
Yes, Community clinic or health care provider
Yes, Certified CLC staff*
Yes, Planned Parenthood
Unknown
*Family Planning Health Worker (FPHW)
If expecting, has the youth been informed of her options to continue or discontinue her pregnancy?
- Select -
N/A - pregnant/expecting
No
Yes, Community clinic or health care provider
Yes, POCC-certified CLC staff
Pregnancy Options Counseling Certification (POCC)*
Other Services
Has the youth participated in Victim Witness Testimony this reporting period?
- Select -
No
Yes
Has the youth been referred or received the California Victim Compensation Board (CalVCB) for compensation/restitution?
- None -
No
No, minor
No, NMD not 21
Youth declined
Yes, referred
Yes, applied
Yes, received the loss of income benefit
Is the youth connected to any other CLC specialty units?
No
DSY Unit
EPY Unit
Education Team
Housing Team
Immigration Unit
MHAT
Peer Advocate Program
PFI Team
Regional Center Unit
Other Services Received
None
ACT Clinic/Dr. Rios
Advocate Services (SI, Zoe, CAST, etc.)
CASA
Mentoring
Public Housing Program
Regional Center
Other
Other Services Not Listed
What advocacy organization is the youth linked to?
- None -
Saving Innocence
Zoe International
Optimist
Vista Del Mar
Journey Out
CAST
Other
If other, specify advocacy organization
