BHS Provider: Fax to (858) 335-3949

Probation/CWS: Email to CFTreferrals@fredfinch.org	AGENCY INVOLVEMENT (check all that apply):
☐ CWS ☐ BHS Provider ☐ Probation
Name of Person Making Referral:
Referring Agency Name:
Date of Referral:	Due Date of Meeting:
Preference for meeting date/Time:	#1:	at	Location:
Preference for meeting date/Time	#2	at	Location:
Part A: To be completed by referring PSW/PO/BHS Provider

PSW/PO Name:
PSW/PO desk and cell #:
PSS/SPO Name:
PSS/SPO desk #:
BHS Provider/Program Name:
BHS Provider Contact Phone:
CWS Program:
CWS Region:
CWS 19-Digit Case/Referral #:
7-Digit State ID #:	HVC?
Probation Region :
Probation Case ID #
Family’s Primary Language:

Family Considerations (ICWA status, military, other cultural consideration such as values, beliefs, lifestyle, traditions, historical trauma, race, ethnicity, language, religion/spirituality, sexual orientation, gender identity expression, and/or learned behavior of a group passed on from generation to generation):
Part B: To be completed for all referrals

Reason for Referral. Check all that apply.
At Risk of Removal
Probation Pre-Disposition
Initial Placement (Probation Post Disposition)
CANS / Case Plan Discussion
Initial- J/D Date:	Update
Change of Placement (every 90 days)
School of Origin:
Pathways to Well-Being – Eligible for Enhanced Services
Mental Health Treatment Needs
GH/STRTP/RTF Placement Review (every 90 days)
End of Voluntary Out of Home Case Plan
Transition Discussions
Compliance with probation conditions
Team member request for Child and Family Team Meeting
Status Review/Case Plan Review and Update/Permanency Planning (including Finalization)

Other (Please specify: post adoption sibling contact agreement, visitation, new team members, progress review):
CFT’s first meeting? Yes No

Current case status and desired meeting outcomes/goals (e.g. Harm/Danger Statement, Safety Goal, Safety, and Risk information, current and/or needed services, etc.):

Focus Child(ren)	List All Children	Focus Child:
Name
Date of Birth
Caregiver Name / Address
Caregiver Phone
Parent/Guardian
Name
Ethnicity
Relationship/To
Phone Number
/
/
/
/
Alerts that must be reviewed prior to scheduling a CFT meeting. If yes to any of the following items, Facilitator must clear the attendee with the PSW/PO before inviting to CFT meeting.
History of Violent Behavior (Specify):
History or current use of alcohol/substances (Specify):
Behavior Health Concerns (Specify):
Domestic Violence:
Current Restraining Order (between which parties?):
Alleged Perpetrator of Sexual Abuse (Specify):
Safety Plan

Please list all other required team members and other potential participants to be invited.

Name/Agency	Relationship to Child(ren)	Phone Number	Requested by: (PSW/PO/MH Provider, Family, Youth)
FFA/STRTP Staff
Mental Health Treatment
Provider for the Youth
CWS Pathways to Well-Being Worker
DSEP Specialist (all 0-5 years old)

BHS Pathways to Well-Being Liaison
Education Representative
Probation Officer
CASA
Tribal Representative
Additional Service Provider
ILS Worker – youth 16+
Emergency RFA Worker
Additional Support
Additional Support
Additional Support
Additional Support

Reminder: Other than required members, youth/family drive team membership. Facilitator will talk with youth/family and PSW/PO about requested team members before inviting other CFT members. Please list all other parties to be noticed:

Name/Agency	Relationship to Child(ren)	Phone Number/Email	Required by:

(Policy, court order, etc.)
Minor’s Counsel	CWS Policy

Child and Family Team Meeting
Referral Form

04-444 (12/19)	Page 2 of 2	County of San Diego/HHSA/PSG

04-444 (12/19)	Page 1 of 2	County of San Diego/HHSA/PSG

Elizarraraz-Lopez, Nancy

2020-03-03

Paule, Shelly

The County of San Diego