COUNTY OF LOS ANGELES DEPARTMENT OF CHILDREN AND FAMILY SERVICES
TECHNICAL ASSISTANCE ACTION REQUEST
CSW NAME/FILE / TELEPHONE # / SCSW /DATE
I. CHILD NEEDS ASSESSMENT
CHECK ALL APPLICABLE BOXES
DETAINED NON-DETAINED EA APPLICATION (YES/NO) INITIAL PLACEMENT REPLACEMENT
NON-PAID PLACEMENT STOP PLACEMENT MCC ASSESSMENT VOLUNTARY PLACEMENT
DATE / DATE /DATE
/DATE
/ DATECHILD’S NAME (Last, First) / DATE OF BIRTH / AGE / SEX
M F
Language / Birthplace / Undocumented Yes No NA
MOTHER’S NAME (Last, First)
/ ADDRESSTELEPHONE NUMBER
/ STATE #PRIORITY #1: PLACEMENT
Search - Please check the appropriate box if you want a specific type of facility:
GH / SFH / FFA / INDIAN HOME / FFH
CONSIDER THE FOLLOWING INFORMATION WHEN ASSESSING FOR A POTENTIAL PLACEMENT AND CHILD-CAREGIVER MATCH (CHECK ALL THAT APPLY)
Alcohol Usage / Mother/Child / Developmentally Disabled / Hyperactive / Gay/Lesbian / Fire Starter
Assaultive Children / Non-ambulatory / Destroys Property / Learning
Disabled / Hearing Impairment / Gang Affiliation
Assaultive towards adults / On-grounds school / Drug Usage / Mentally Ill / Self-destructive / Vision Impairment
Depression/
Chronic / Physical Disability / Dual Diagnosis / Infant Drug/Alcohol
SB 1173 Training / Sexually Acting Out / Severely Emotionally Disturbed (SED)
Shelter Care / Pregnant / Emancipation ILP / Runaway / Sexually
Predatory / Smoking / Tobacco Usage
Sibling in System / Psychotropic Drugs / Emergency Placement / School Problems / Suicidal / Indian Child
Seizure Disorder / Special Health Care Needs / Encopretic / Enuretic / Theft / Other: Specify
II. CHILD PLACEMENT NEEDS ASSESSMENT – CHILD-CAREGIVER MATCH
Complete as part of the selection process
A. Check one of the following to indicate where child is placed, the type of placement selected:
Licensed Foster Family Home
Relative
Former Relative (Post TPR eligibility)
Non-Relative Extended Family Member
Tribe Approved Home (if child meets the provisions of the Indian Child Welfare Act)
FFA/Certified Foster Family Home
Group Home. ARA signature required
County Operated Emergency Shelter Care, i.e., MCC
Congregate Care (child age six or younger, i.e., 0-83 months, inclusive), ARA signature required
Small Family Home
Non-Paid Placement, i.e., Hospital Hold, Psychiatric Hospital
Caregiver/Relative Name ______
Address (include city and zip code) ______
Telephone Number (include area code) ______
Relative/Non-Relative Extended Family Member Home Approved (DCFS 723 effective date) ______
Placement Date ______
Foster Care Rate (out of county/out of state) ______
Contact person; provide name, address and telephone number for out of county and out of state placement
______
______
B. PLACEMENT LOCATION: (Check all applicable placement factors below)
Placement located in child’s own area
Placement not located in child’s own area
PLACEMENT WILL (Check all that apply):
Assist in reunification
Protect child from parents
Maintain family ties
PLACEMENT CHOSEN BECAUSE:
Siblings placed together
Placed with relative(s)
Placed with non-relative extended family member(s)
No vacancies in the child’s area
Consideration of child’s mental health and treatment needs
Child over age 10 expressed preference
Emergency shelter care needed. Unable to locate appropriate placement. ARA signature required
if placement exceeds thirty days.
If the placement is located out of the child’s own area/ region, explain efforts made to place the child
within his or her own region.
______
______
PRINT PLACEMENT PACKAGE - INCLUDES THE MEDI-CAL CARD/AUTHORIZATION LETTERStart Date / Caregiver Name / Caregiver Address / Relationship
Start Date / Caregiver Name
/ Caregiver Address
/ Relationship
If you do not want a clothing allowance issued, place a check in this box
If placing a child in an FFA, provide the caregiver’s name, specific street address and city of the child’s placement
______
FFA Caregiver’s Name
Street Address City State Zip Code
NOTE: A request for congregate care, emergency shelter care or other specialized placement must have appropriate signatures and must be shown to the TA/Eligibility Worker before the placement packet is picked up.
C. ADDITIONAL REQUESTS
PRIORITY #2: OTHER REQUESTS:Initiate
AAP / Medi-Cal Card
Verification / Pick-Up / Mail BIC / Child Name:
VITAL STATISTICS / SSN / Birth Certificate / Death Certificate
Date:
Place:
Parent(s) Name:______
Mother Mother’s maiden name
______
Father
Infant Supplement: Name______Birth Date ______
Inter-County Transfer To:______(Court Order attached)
Other (specify):
CSW Signature ______Date __________
SCSW Signature______ Date ______
ARA Signature________Date ______
DCFS 280 (Rev 02/02) Page 4 of 4