SERVICE REQUEST AND REFERRAL
Referral Date (mm/dd/yyyy)[tm1] / Type of Service
AFTERCARE-ISSALCOHOL AND OTHER DRUG SCREENING PROGRAMANGER MANAGEMENTCASE STAFFINGCOGNITIVE RESTRUCTINGCOMMUNITY SERVICEELECTRONIC MONITORING PROGRAMFOUR WEEK FAMILY EDUCATION PROGRAMHOMME HOME-CAPINTENSIVE IN-HOMEINTENSIVE SUPERVISIONINTENSIVE REUNIFICATION PROGRAMOTHERPLACEMENT REQUEST/AUTHORIZATIONSHOCAPSUPPORT SERVICE WORKERVICTIM-OFFENDER CONFERENCING[tm2] / County
[tm3]
Other
[tm4]
Child / Juvenile Information
Name - Child / Juvenile
[tm5] / Birthdate (mm/dd/yyyy)
[tm6]
Gender
[tm7]Male[tm8] Female / Race
[tm9] / Hispanic
[tm10] Yes[tm11] No
Address - Child / Juvenile (Street, City, State, Zip Code)
[tm12] / Telephone Number
[tm13]
Present Living Situation
[tm14]
Name - Present Care Provider
[tm15]
Name - School
[tm16] / Current Grade
[tm17]
[tm18]Yes [tm19] No Is this child / juvenile on Medical Assistance? / Medical Assistance Number
[tm20]
[tm21]Yes [tm22] No Does this child / juvenile meet criteria for severe emotional disturbance?
Mother Information
Name (Last, First, Middle)
[tm23] / Birthdate (mm/dd/yyyy)
[tm24]
Address (Street, City, State, Zip Code)
[tm25] / Telephone Number - Home
[tm26]
Name - Employer
[tm27] / Is work contact permitted?
[tm28] Yes[tm29] No / Telephone Number - Work
[tm30]
Father Information
Name (Last, First, Middle)
[tm31] / Birthdate (mm/dd/yyyy)
[tm32]
Address (Street, City, State, Zip Code)
[tm33] / Telephone Number - Home
[tm34]
Name - Employer
[tm35] / Is work contact permitted?
[tm36] Yes[tm37] No / Telephone Number - Work
[tm38]
Household / Family Members Information
Name / Gender / Relationship / Birthdate (mm/dd/yyyy) / Age
[tm39] / [tm40] Male [tm41] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm42] / [tm43] / [tm44]
[tm45] / [tm46] Male [tm47] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm48] / [tm49] / [tm50]
[tm51] / [tm52] Male [tm53] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm54] / [tm55] / [tm56]
[tm57] / [tm58] Male [tm59] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm60] / [tm61] / [tm62]
[tm63] / [tm64] Male [tm65] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm66] / [tm67] / [tm68]
[tm69] / [tm70] Male [tm71] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm72] / [tm73] / [tm74]
[tm75] / [tm76] Male [tm77] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm78] / [tm79] / [tm80]
[tm81] / [tm82] Male [tm83] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm84] / [tm85] / [tm86]
[tm87] / [tm88] Male [tm89] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm90] / [tm91] / [tm92]
[tm93] / [tm94] Male [tm95] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm96] / [tm97] / [tm98]
[tm99] / [tm100] Male [tm101] Female / AuntBrotherCousinGrandfatherGrandmotherFamily FriendNephewNieceParent's BoyfriendParent's GirlfriendSisterStep-FatherStep-MotherUncleOther[tm102] / [tm103] / [tm104]
[tm105]
Presenting Problem(s) of Child / Juvenile
[tm106]
Prior Services
[tm107]Individual therapy
[tm108]Family counseling
[tm109]Group therapy
[tm110]Intensive in-home
[tm111]Parent-aide
[tm112]Psychological evaluation / [tm113]Psychiatric evaluation
[tm114]Independent living
[tm115]Day care
[tm116]EMP
[tm117]UA / drug screening
[tm118]AODA evaluation / [tm119]AODA out-patient Tx
[tm120]AODA in-patient Tx
[tm121]Medication treatment
[tm122]Medical exam
[tm123]Shocap
[tm124]Parenting classes / [tm125]Supervised visitation
[tm126]Community service
[tm127]Intensive supervision
[tm128]Transportation assistance
[tm129]Other-Specify: / [tm130]
Placement History
[tm131]Secure detention
[tm132]TFC
[tm133]Respite care
[tm134]Relative placement / [tm135]Chapter 51 in-patient
[tm136]Shelter home
[tm137]Foster care / [tm138]Group care
[tm139]Residential treatment
[tm140]Juvenile corrections
Additional Information
[tm141]
Family History
[tm142]Abuse / neglect
[tm143]Lack of supervision
[tm144]Parenting issues
[tm145]AODA issues
[tm146]Criminal behavior
Additional Information
[tm147]
Educational / Social Background
[tm148]Truancy issues
[tm149]Failing grades
[tm150]Behavior problems
[tm151]Alcohol / drug use / abuse / [tm152]Ed programming
[tm153]LD programming
[tm154]Incomplete schoolwork / [tm155]Gang issues
[tm156]Poor social skills
[tm157]Delinquent peer group
Additional Information
[tm158]
Criminal History
[tm159]History of violence
[tm160]History of weapons / [tm161]Gang member / association
[tm162]Deferred prosecution agreement
Additional Information
[tm163]
Identified Needs / Areas of Concern
[tm164]
Strengths of Youth and / or Family
[tm165]
Additional Information
[tm166]
Supervisor's Comments
[tm167]
Signatures
[tm168]SIGNATURE - Worker / Date Signed
[tm169]
SIGNATURE - Supervisor / Date Signed
Service Request and ReferralPage 1 of 3
CFS-2318W (Rev. 02/2004)
[tm1]1This field is user-entered.
[tm2]1This field is user-selected.
[tm3]11This field is pre-filled.
This field is not editable on the template.
This field can be corrected as follows: The County pre-fills with the county name of the worker who created the template. If this is incorrect, the worker's supervisor needs to update the worker's county in the worker's Maintain Worker Information page.
[tm4]1This field is user-entered.
[tm5]1This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the case participant's name can be changed in the First/Last Name fields on the participant's Person Management page/Basic tab.
[tm6]1This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the case participant's Birth Date can be changed in the Birth Date field on the participant's Person Management page/Basic tab.
[tm7]1This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the gender can be modified on the participant's Person Management page.
[tm8]11This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the gender can be modified on the participant's Person Management page.
[tm9]11This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the primary race can be modified on the participant's Person Management page.
[tm10]11This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: Hispanicorigin can be modified on the participant's Person Management page.
[tm11]1This checkbox pre-fills if the participant selected as the Child / Juvenile on the template is not Hispanic as documented on the Person Management page. The result can be modified on the Person Management page for the participant selected.
[tm12]1This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the child’s address can be changed in the Address field on the Person Management page/Address tab.
[tm13]1This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the child’s telephone number can be changed in the Address field on the Person Management page/Address tab.
[tm14]1This field is user-entered.
[tm15]This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the field displays current provider for Out of Home Placement. If child is not placed out of home, the field will be blank.1
[tm16]1This field is user-entered.
[tm17]1This field is user-entered.
[tm18]1This field is user-selected.
[tm19]1This field is user-selected.
[tm20]1This field is user-entered.
[tm21]1This field is user-selected.
[tm22]1This field is user-selected.
[tm23]11This field is pre-filled.
The field is not editable on the template.
The data can be corrected as follows: the mother's name can be changed on the mother's Person Management page/Basic tab. A new person can be selected as Mother on the child's Person Management page/Parent Info tab.
[tm24]1This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the Birth Date can be changed in the Birth Date field on the mother's Person Management page/Basic tab.
[tm25]11This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the address can be changed in the Address field on the mother's Person Management page/Address tab.
[tm26]11This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the telephone number can be changed in the Home Phone field on the mother's Person Management page/Addresstab.
[tm27]1This field is user-entered.
[tm28]1This field is user-selected.
[tm29]1This field is user-selected.
[tm30]1This field is user-entered.
[tm31]111This field is pre-filled.
The field is not editable on the template.
The data can be corrected as follows: the father's name can be changed on the father's Person Management page/Basic tab. A new person can be selected as Father on the child's Person Management page/Parent Info tab.
[tm32]11This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the Birth Date can be changed in the Birth Date field on the father's Person Management page/Basic tab.
[tm33]111This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the address can be changed in the Address field on the father's Person Management page/Address tab.
[tm34]111This field is pre-filled.
This field is not editable on the template.
The data can be corrected as follows: the telephone number can be changed in the Home Phone field on the mother's Person Management page/Addresstab.
[tm35]This field is user-entered.1
[tm36]This field is user-selected.1
[tm37]1This field is user-selected.
[tm38]1This field is user-entered.
[tm39]1This field is user-entered.
[tm40]1This field is user-selected.
[tm41]1This field is user-selected.
[tm42]1This field is user-selected.
[tm43]1This field is user-entered.
[tm44]1This field is user-entered.
[tm45]1This field is user-entered.
[tm46]1This field is user-selected.
[tm47]1This field is user-selected.
[tm48]1This field is user-selected.
[tm49]1This field is user-entered.
[tm50]1This field is user-entered.
[tm51]1This field is user-entered.
[tm52]1This field is user-selected.
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[tm54]1This field is user-selected.
[tm55]1This field is user-entered.
[tm56]1This field is user-entered.
[tm57]1This field is user-entered.
[tm58]1This field is user-selected.
[tm59]1This field is user-selected.
[tm60]1This field is user-selected.
[tm61]1This field is user-entered.
[tm62]1This field is user-entered.
[tm63]1This field is user-entered.
[tm64]1This field is user-selected.
[tm65]1This field is user-selected.
[tm66]1This field is user-selected.
[tm67]1This field is user-entered.
[tm68]1This field is user-entered.
[tm69]1This field is user-entered.
[tm70]1This field is user-selected.
[tm71]1This field is user-selected.
[tm72]1This field is user-selected.
[tm73]1This field is user-entered.
[tm74]1This field is user-entered.
[tm75]1This field is user-entered.
[tm76]1This field is user-selected.
[tm77]1This field is user-selected.
[tm78]1This field is user-selected.
[tm79]1This field is user-entered.
[tm80]1This field is user-entered.
[tm81]1This field is user-entered.
[tm82]1This field is user-selected.
[tm83]1This field is user-selected.
[tm84]1This field is user-selected.
[tm85]1This field is user-entered.
[tm86]1This field is user-entered.
[tm87]1This field is user-entered.
[tm88]1This field is user-selected.
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[tm90]1This field is user-selected.
[tm91]1This field is user-entered.
[tm92]1This field is user-entered.
[tm93]1This field is user-entered.
[tm94]1This field is user-selected.
[tm95]1This field is user-selected.
[tm96]1This field is user-selected.
[tm97]1This field is user-entered.
[tm98]1This field is user-entered.
[tm99]1This field is user-entered.
[tm100]1This field is user-selected.
[tm101]1This field is user-selected.
[tm102]1This field is user-selected.
[tm103]1This field is user-entered.
[tm104]1This field is user-entered.
[tm105]1This field is user-entered.
[tm106]1This field is user-entered.
[tm107]1This field is user-selected.
[tm108]1This field is user-selected.
[tm109]1This field is user-selected.
[tm110]1This field is user-selected.
[tm111]1This field is user-entered.
[tm112]1This field is user-selected.
[tm113]1This field is user-selected.
[tm114]1This field is user-selected.
[tm115]1This field is user-selected.
[tm116]1This field is user-selected.
[tm117]1This field is user-selected.
[tm118]1This field is user-selected.
[tm119]1This field is user-selected.
[tm120]1This field is user-selected.
[tm121]1This field is user-selected.
[tm122]1This field is user-selected.
[tm123]1This field is user-selected.
[tm124]1This field is user-selected.
[tm125]1This field is user-selected.
[tm126]1This field is user-selected.
[tm127]1This field is user-selected.
[tm128]1This field is user-selected.
[tm129]1This field is user-selected.
[tm130]1This field is user-entered.
[tm131]1This field is user-selected.
[tm132]1This field is user-selected.
[tm133]1This field is user-selected.
[tm134]1This field is user-selected.
[tm135]1This field is user-selected.
[tm136]1This field is user-selected.
[tm137]1This field is user-selected.
[tm138]1This field is user-selected.
[tm139]1This field is user-selected.
[tm140]1This field is user-selected.
[tm141]1This field is user-selected.
[tm142]1This field is user-selected.
[tm143]1This field is user-selected.
[tm144]1This field is user-selected.
[tm145]1This field is user-selected.
[tm146]1This field is user-selected.
[tm147]1This field is user-entered.
[tm148]1This field is user-selected.
[tm149]1This field is user-selected.
[tm150]1This field is user-selected.
[tm151]1This field is user-selected.
[tm152]1This field is user-selected.
[tm153]1This field is user-selected.
[tm154]1This field is user-selected.
[tm155]1This field is user-selected.
[tm156]1This field is user-selected.
[tm157]1This field is user-selected.
[tm158]1This field is user-entered.
[tm159]1This field is user-selected.
[tm160]1This field is user-selected.
[tm161]1This field is user-selected.
[tm162]1This field is user-selected.
[tm163]1This field is user-entered.
[tm164]1This field is user-entered.
[tm165]1This field is user-entered.
[tm166]1This field is user-entered.
[tm167]1This field is user-entered.
[tm168]1This field is user-entered.
[tm169]1This field is user-entered.