Referral Source (RS):*

RS's Phone Number*

RS's Cell Number:

RS E-mail Address:*

Family Name:*

Date of Referral:*

Name of subject child(ren) meeting will serve:*

Please add information below regarding subject child with the birthday closest to the referral date.

Child's Race:*

White/Caucasian Black/African American Multiracial Native American/Alaskan/Hawaiian Asian/Pacific Islander Other

Ethnicity:*

Hispanic Not Hispanic/Latino

Sex:*

Male Female

Age:

MCI# (if known):

Does child or has child had previous CYS involvement? *

Yes No Unknown

Is child involved with JPO?*

Yes No Unknown

What is the primary purpose of the Family Group Conference/Family Team meeting? *

To develop/revise an Independent Living (IL) plan/ Aftercare/Final Transition Plan To develop a plan to keep the child in a safe & stable home To develop a plan to prevent placement To develop a plan to transition a child to a new placement setting To develop a plan to prevent an out-of-home placement disruption To plan and assist in reunification To identify support for caregivers To develop a plan that addresses the lack of supervision of a child To develop a plan to improve communication To develop a plan that addresses child/family/ parent conflict To develop a plan that addresses child’s medical/mental health/ drug & alcohol issues To develop a plan to address child/youth’s behavioral issues To develop a plan to prevent further delinquent behavior To develop a plan to prevent truancy To develop a plan that addresses housing & environmental issues To develop a plan that addresses parent’s medical/mental health/ drug & alcohol issues

Personalized purpose statement developed with the family: *

Describe the living situation for the child(ren), to include where the child(ren) currently resides and with whom (i.e. parent’s home, formal kinship, foster care, informal kinship, RTF, etc.): *

Overview of the family’s strengths: *

Overview of the family’s concerns/ needs, include any issues involving any drug and alcohol, mental health, domestic violence, child abuse/ neglect, PFAs : *

List the non –negotiables (legality & safety issues only) and describe the current safety plan if applicable:

Please use this space to provide any additional information that would be helpful when planning this conference:

Please use this space to explain how urgent the conference is. Please be specific about time frames and if this conference needs to take place before an upcoming court hearing, discharge date, or on an emergency basis. *

Please identify your availability for a conference and if possible the family’s availability for a conference. Please note if you are not at all available on evenings or weekends.*

Please list information for primary caregiver(s) / child(ren) in the family, as well as each service provider or natural support person you feel should be invited to the meeting. This list will be reviewed with the family for final approval.

Name | Relationship to Child | Address | E-mail Address | Phone Number | Additional Information about Participant Pertinent to the Meeting