Form Cfs 968 54A PDF Details

In the realm of child welfare, the completion and submission of specific forms stand as critical steps toward ensuring that children in need receive appropriate care and support. Among these forms, the CFS 968-54A, revised in July 2003 by the State of Illinois Department of Children and Family Services, plays a pivotal role in the System of Care (SOC) referral process. Designed to be filled out by a child's caseworker, this form initiates the procedure for referring a child to the SOC program. It captures extensive information, including the date of the referral, placement details, child's personal information such as name, ID, date of birth, gender, primary language, and the opening date of their Department of Children and Family Services (DCFS) case. Additionally, it delves into foster parent details, the caseworker's agency and supervisor information, the child's current setting, a record of services provided in the last year, and the specifics regarding any step-down in service. Moreover, the form includes sections for describing the issues prompting the referral and the desired outcomes from the SOC, complemented by a checklist for further information needed and a space for caseworker and supervisor signatures. This comprehensive approach ensures a thorough understanding of the child's situation and needs, facilitating targeted support through the SOC system.

QuestionAnswer
Form NameForm Cfs 968 54A
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesCFS_968 54A_System_of_C are_(SOC)_Refer ral_Form_(Filla ble) illinois soc referral form

Form Preview Example

CFS 968-54A

Rev. 7/2003State of Illinois

Department of Children and Family Services

System of Care (SOC) Referral Form

Directions: This form must be completed by the child’s caseworker to begin the SOC referral process.

Date of Referral:

 

 

LAN of Placement:

 

 

 

 

 

 

Child Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

Child ID:

 

 

 

 

 

DOB:

 

Gender:

 

 

 

Child Primary Language:

 

 

 

 

 

 

Date of DCFS Case Opening:

 

 

 

Foster Parent(s) Name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foster Parent Address

 

 

 

 

 

 

 

 

 

 

Zip Code

 

 

Foster Parent Phone:

 

 

 

 

 

Foster Parent Primary Language:

 

 

 

 

 

 

Caseworker Agency:

 

 

 

 

 

 

Caseworker Name:

 

 

 

 

 

 

Caseworker Agency Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Caseworker Phone:

 

 

 

 

Caseworker Fax:

 

 

 

 

 

 

Supervisor Name:

 

 

 

 

 

Supervisor Phone:

 

 

 

 

 

 

Current Setting:

 

 

 

Prior Services (last year):

 

 

 

 

 

POS Traditional/HMR Foster Home POS Specialized Foster Home DCFS Foster Home

Home of Parent Emergency Shelter Instituion/Group Home Hospitalization due to medical condition Psychiatric Hospitalization

Other, Specify Setting:

Counseling/Therapy

Tutoring

Psychological Assessment

Respite

Substance Abuse Treatment

Mentoring

Speech/Occupational/Physical Therapy Recreational (i.e., memberships)

Medical Assessment/Treatment (beyond routine care) Special Educational Services

SASS

If requesting SOC services because the child is stepping-down, please indicate the following:

Future setting:

 

Expected Step-Down Date:

14 Day Notice of Placement Change has been Issued:

Yes

No

Briefly describe the presenting issues that have caused you to seek assistance from SOC, and state specifically what you are seeking from SOC (pertinent documentation may also be attached). Include why the referral is being made now:

Caseworker Signature:

 

 

Date:

Supervisor Signature:

 

 

 

Date:

SOC Provider:

 

 

 

Child Name:

 

FP Phone Number(s)

 

Best Time to Call

 

FP Work:

Beginning:

am/pm

End:

am/pm

FP Home:

Beginning:

am/pm

End:

am/pm

FP Other:

Beginning:

am/pm

End:

am/pm

Child ID:

Check Available Days

S M T W T F S

S M T W T F S

S M T W T F S

Additional Information Requested

θDCFS Client Service Plan

θPsychological Assessments -- Type:

θAdditional Collateral Information -- Type:

θCounseling Reports—Type:

θInitial Social History/Comprehensive Assessment/Addendums

θRelease(s) of Information (needed for release of confidential information)

θOther -- Type:

For SOC Staff Use Only: * Additional information collected directly from referring caseworker (i.e., type,

frequency of services, etc.):

SOC Disposition

θ

θ

Acceptance of the referral

Refer back to DCFS or foster care agency: Reason(s) case is being referred back to DCFS or foster

care agency, including recommendations for service/intervention:

SOC Worker Signature:

 

Date:

*After making a disposition decision, the SOC provider must fax this completed form to the referring caseworker within two days of receiving the referral.

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