Documented Efforts to Prevent Emergency Shelter Placement

CFS 1452-4

12/2014

State of Illinois

Department of Children and Family Services

Documented Efforts to Prevent Emergency Shelter Placement

Select One: Disruption DCP Dependency
Youth Personal Information
Youth’s Name: / ID#: / DOB: / Age:
Gender: Select OneMaleFemale / Race: Select OneNative American/Alaskan (Indian or Eskimo)AsianBlack/African AmericanNataive Hawaiian/Pacific IslanderWhiteUnknownDeclined to IdentifyCould not be Verified / Ethnicity: Select OneNot Hispanic (None)Hispanic South AmericanHispanic MexicanHispanic Puerto RicanHispanic Spanish DescentHispanic CubanHispanic Central AmericanHispanic DominicanHispanic OtherUnknownDeclined to IdentifyCould not be Verified / Weight: / Height:
Legal Status: Select OneAR - Adoptive RightsCO - CRT Order SPVSCT - Court No JurisdictionGO - Guardianship onlyPC - Protective CustodyTC - Temporary CustodyTR - Temporary CustodyTW - Temporary Custody / Permanency Goal: Select OneNot EstablishedReturn Home Concurrent PlanningReturn Home Within 5 MonthsReturn Home Within 1 YearReturn Home Pending Status HearingSubsidized GuardianshipAdoptionGuardianshipIndependenceOut of Home Care
Special Needs 1: Select OneLGBTDD/Low IQDomestic Violence (Victim)Domestic Violence (Perp)Substance AbuseEarly ChildhoodNurseCYSBPSerious MINA / Special Needs 2: Select OneLGBTDD/Low IQDomestic Violence (Victim)Domestic Violence (Perp)Substance AbuseEarly ChildhoodNurseCYSBPSerious MINA / Other Special Needs:
Native/Alaskan American Indian: Yes No / Deaf/HOH: Yes No
Burgos: Yes No / Other Language Needs: Yes No / Language Needed:
Pregnant or Parenting? Yes No / If Yes, Age(s) of Children:

Case Management Information:

Agency Name: / R/S/F:
Worker/Child Protection Specialist: / Phone: / Ext: / Fax:
Supervisor: / Phone: / Ext: / Fax:

* To be completed whenever seeking approval for shelter placement.

Efforts to Avoid Shelter Placement:

What resources (foster home: POS & DCFS, Relatives) have been sought to prevent emergency shelter placement? It is an expectation that alternative resources are explored in order for children/youth to be admitted to the shelter.
List information on all contacts made below:
Date/Time: / Agency/Resource Contacted: / Name of Contacted Party:
*Include the name of agency staff contacted and all relatives, potential foster parents or other resources contacted in attempt to secure placement / Outcome/Reason Placement not Selected:
*Include the outcome of the inquiry and reason placement was not selected /

What is the expected length of placement in shelter care?

Rationale:

Rationale for seeking shelter placement:
I certify that the information contained herein is accurate and details all attempts made to avoid placing the child/youth in a shelter placement.
Worker/Child Protection Specialist:
Supervisor:

Page 1 of 4