Placement and Recruitment Unit

COUNTY OF LOS ANGELES DEPARTMENT OF CHILDREN AND FAMILY SERVICES

PLACEMENT AND RECRUITMENT UNIT

CHILD/FAMILY MATCH

Date:

To:

Child’s CWS

/ Telephohe Number/Fax Number
From:

PRU CSW

/ Telephone Number
NAME OF CHILD(REN)

A potential adoptive family has been identified for your child. Please review the attached child/family information sheet and contact the Applicant CSW at the telephone number listed below within 10 working days to discuss this match. After a decision has been made regarding the appropriateness of the match, please complete the following information and fax this form to me at (213) 383-1502.

Applicant Family Name:

Applicant CSW

/

Telephone Number

APPROPRIATE MATCH: Yes No

If yes, date of the scheduled pre-placement conference: / If no, state the
reason the above-named family was not selected and obtain ARA approval:

Would you like an additional family? Yes No

Was the family contacted regarding the child(ren)? Yes No

If yes, by whom?
Date of the scheduled presentation?
CSW / Date / SCSW / Date
ARA / Date

DCFS/A 5400-1 (REV 10/00)