CP&P 26-93

(rev. 10/2018)

FPS ID #:______

New Jersey Department of Children and Families • Division of Child Protection and Permanency

Family Preservation Services

Referral Form

DATE / CP&P Local Office / Main Phone / FAX
Intake Permanency Caseworker: / Ext.
Name / State Cell Phone / State E-mail
CP&P Supervisor: / Ext.
Name / Phone / State E-mail
Family Name / NJ CASE ID No.
Address: / Telephone:
Street / Apt. No.
Language Spoken:
City/Town / State / Zip Code
Adults Living in Family or Resource Home / Relationship
to Child / Gender
(M/F) / Age / DOB
Mo/Day/Yr / Cell Phone / Comments
Children in home/Children to be reunified / CP&PService Goals: (1) Stabilize in Home (2) Reunification (3) Stabilize in Placement
Last Name / First Name / Child ID# / Age / DOB
Mo/Day/Yr / Gender
(M/F) / In Home
Y/N / CP&P Service Goals
(Enter 1, 2,or 3)
Others Living in Home & Relationship to Family
Environmental Concerns for Staff
(bed bugs, pets, drug/gang activity, weapons, smoke, etc)
Source of Risk / Family Stress Factors (check all that apply)
Physical Abuse
Emotional Abuse
Sexual Abuse
Neglect / Housing Related Issues
History of Domestic Violence
Financial/Unemployment
Delinquency / Physical Health (Parent)
Mental Health (Parent)
Disability (Parent)
Substance Abuse (Parent) / Physical Health (Child)
Mental/Behavioral Health (Child)
Substance Abuse (Child)
Disability (Child)
SDM Assessments
(attach at least 1) / Safety Assessment (one or more safety factors identified in Section1)
Family Risk Assessment/Re-Assessment (risk is high or very high)
Family Reunification Assessment (risk is low to moderate & one or more safety factors present in Part 2)
Other Relevant Documents
(attach at least 1) / CP&P Case Plan (26-51 or 26-81)
Court Order/Complaint
Relevant Reports / SDM Caregivers Strengths and Needs
SDM Risk Assessment/Re-Assessment
SDM Safety Assessment
FPS Services Requested (do not check off more than 4)
Safety Strategies
Household Management
Budget/Finance Management
Structuring Daily Routines/Time Mgmt.
Concrete Services (food, shelter clothing, etc) / Parenting Skills Instruction
Behavior Management
Communication Skills
Anger Management/Conflict Resolution
Stress Management/Coping Skills / Support Substance Abuse Recovery
Support Mental Health Treatment
Support Health/Medical Care
Employment Assistance
Accessing Community/Natural Resources
Additional Information (Required)
Describe the current crisis, complaint, or incident that prompted the family’s referral to FPS:
List each FPS Service Requested (checked off above)and describe the specific behavioral changes needed relative to the CP&P Service Goals:
Reviewed by Screener
Name / Phone / State E-mail
FOR FPS PROGRAM USE ONLY
Received by FPS Supervisor / Referral Accepted:
Date / Time / Yes/No

Turn Back Code:

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