If requesting IPS services because the child is stepping-down, indicate the future setting, the expected step-down date, and whether the 14 Day Notice of Placement Change has been Issued (Yes or No).
Presenting issues: briefly describe the presenting issues that have caused you to seek assistance from IPS, and state specifically what you are seeking from IPS.
Why now: include why the referral is being made now.
Disposition: after making a disposition decision, the IPS provider must fax this completed form to the referring caseworker within two days of receiving the referral.
Release(s) of Information: needed for release of confidential information.
Signatures: Caseworker Signature and Supervisor Signature, each with a Date.
| Question | Answer |
|---|---|
| Form Name | CFS 968-54A |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 116 |
| Avg. time to fill out | 20 min |
| Edition | 6/2015 |
| Issuing agency | State of Illinois Department of Children and Family Services |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | CFS 968-54A, CFS 968-54, Illinois CFS 968-54A, IPS referral form, Intensive Placement Stabilization Referral Form |
| Official source | CFS 968-54A (Rev 6/2015), State of Illinois Department of Children and Family Services |
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