Family Resource Center Referral Form
Kinship, Parenting Education, My Community Cares, Parent Partner
Referring Party Type
*
Please Select
DCFS-FC
DCFS-FS
DCFS-CI
DCFS-HD
DCFS-Extended Foster Care
DCFS-Adoptions
DCFS-Step
FINS
Other State Agency
Medical Organization
School
Law Enforcement Agency
Community Agency
Court System
Self-Referral
DCFS Case #
What services are you requesting?
*
Kinship Services
My Community Cares
Parenting Education
MCC- Legal Services
Parent Partner (DCFS Only)
TBRI® Advocate
Parenting Education Type
Nurturing Parenting
TBRI®
No Preference
Referring Party's Information
Referring Party's Name
*
First Name
Last Name
Referring Party Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Party Email
example@example.com
Referring Party's DCFS Department Affiliation
*
Investigations
Family Services
Foster Care
Extended Foster Care
Home Development
Adoptions
Adult Clients Referred
Primary Client's Name
*
First Name
Last Name
Gender
Please Select
Male
Female
N/A
Date of Birth
-
Month
-
Day
Year
Ethnicity
Please Select
African American
Asian/Pacific Islander
Caucasian
Hispanic
Native American
Marital Status
Please Select
Single
Married
Separated
Divorced
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list name, date of birth, phone number, email address, and relationship to the client for all other adult household members.
Child's Information
How many children are within this family unit?
*
Any more than 4 will be listed in the additional space.
Primary Client's Relationship to Child #1
Parent
Guardian
Fictive Kin
Relative
Foster Caregiver
Other
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Race
Please Select
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
Is child #1 placed with the primary client?
Please Select
Yes
No, placed with a relative
No, placed in non-relative foster care
No. placed with fictive kin
No, placed in residential facility
Please list name, relationship, phone number, and address of placement for child #1.
Primary Client's Relationship to Child #2
Parent
Guardian
Fictive Kin
Relative
Foster Caregiver
Other
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Race
Please Select
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
Is child #2 placed with the primary client?
Please Select
Yes
No, placed with a relative
No, placed in non-relative foster care
No. placed with fictive kin
No, placed in residential facility
Please list name, relationship, phone number, and address of placement for child #2.
Primary Client's Relationship to Child #3
Parent
Guardian
Fictive Kin
Relative
Foster Caregiver
Other
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Race
Please Select
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
Is child #3 placed with the primary client?
Please Select
Yes
No, placed with a relative
No, placed in non-relative foster care
No. placed with fictive kin
No, placed in residential facility
Please list name, relationship, phone number, and address of placement for child #3.
Primary Client's Relationship to Child #4
Parent
Guardian
Fictive Kin
Relative
Foster Caregiver
Other
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
N/A
Race
Please Select
American Indian/Alaska Native
Asian
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White/Caucasian
Is child #4 placed with the primary client?
Please Select
Yes
No, placed with a relative
No, placed in non-relative foster care
No. placed with fictive kin
No, placed in residential facility
Please list name, relationship, phone number and address of placement for child #4.
Please list name, date of birth, race, gender and relationship to primary client, and placement information for all other children.
Information Required for Legal Services
Name of Adverse Party:
Number of People Living in the Household:
Total Household Income
Source of Income:
What VYJ Program are you currently involved in?
Are you a citizen or an eligible alien of the USA?
Yes
No
Previous/Current Services Provided for Family/Child
What Services are currently being provided to the family?
Dept. of Children & Family Services OCS/OJJ
Probation
Counseling/Mental Health Services
Substance Abuse/Drug Services
Educational/Tutoring
Mentoring
Other
Please give agency name and contact information for each service provided
In a few sentences, please provide an overview of family circumstances
Please list any additional information that would be helpful in determining the needs of the client. Please provide details. (Background, psychological/medical history, court involvement, etc.)
In a few sentences, please let us know how the FRC can assist your family.
Please upload the latest documents applicable to the case.
Browse Files
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Choose a file
Files may include: Safety Assessment, CSP Court Ordered Safety Plan, ISP Instanter Order Safety Plan, SP CW Safety Plan, Form XI (services requested for foster/adoptive home), Trauma and Behavioral Health Screen, Assessment of Family Functioning, Case Plans, and Youth Transition Plans.
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