2919 Mission Street San Francisco, CA 94110 415-229-0500 (Office) 415-647-0740(Fax)

Instituto Familiar de la Raza, Inc.

2919 Mission Street  San Francisco, CA 94110 415-229-0500 (Office) 415-647-0740(Fax)

La Cultura Cura

Referral Form

(Last Updated: January 2017)

Serving Mission District youth between the ages of 12-24, and Latinos citywide

Youth Information

Referral Date:

Name: Date of Birth: Age: Gender Identity:

Ethnicity/Family Country of Origin: Place of Birth: Years in U.S.:

Preferred Language: School: Grade:

Home Address: Zip Code: Youth Phone Number: OK to Call: Y N
(Full address and zip code needed in case we cannot contact client by phone)

CaregiverName: Caregiver Phone Number(s): OK to Call: Y N

Caregiver Preferred Language:  Biological Parent  Non-Parent Caregiver  Legal Custody

Concerns/Risk Factors/Needs

PLEASE NOTE: This information is being sent for an expressed purpose of service and may contain privileged and confidential information intended for the individual (s) indicated above. If you are NOT the intended recipient, or the employee or agent responsible to deliver this written information to the intended recipient, you are hereby notified that any use, dissemination, distribution, or copying of this information is strictly prohibited.

Instituto Familiar de la Raza, Inc.

2919 Mission Street  San Francisco, CA 94110 415-229-0500 (Office) 415-647-0740(Fax)

Police Contact

 Formal/Informal Probation

 Imitating Risky Lifestyle

 At-Risk for Street Activity

 Violence/Aggressive Behavior

Escalation of Mental Health Needs

 Trauma Exposure

 Substance Use/ Abuse

 Employment Needs

Truancy/Attendance

 Peer Relationship Concerns

 Bullying/Harassment

LGBTQ Support

 Abuse/Neglect

 Family Reunification

 Recently Relocated

 Pregnancy/Parenting

 Suicidal Ideation/Self-Harming

Legal Support- Juvenile Justice

Legal Support- Immigration

 Medical Health Concerns

 Needs/Has Individualized Education Plan

 Housing/Living Situation

Basic Needs (Food, Clothing, Shelter)

Instituto Familiar de la Raza, Inc.

2919 Mission Street  San Francisco, CA 94110 415-229-0500 (Office) 415-647-0740(Fax)

What services are they looking for?(Select all that apply) Mental Health Case Management Group

Reason for Referral

Is client is working with other providers? (ie. Social worker, therapist, case manager, school counselor)

Name: Phone Number:

Referral Source

Name Job Title: Agency:

Work Phone: Cell Phone: E-mail Address:

Has the youth or family been informed of the referral to IFR services?Yes No If not, please explain:______

IF CLIENT HAS NOT BEEN INFORMED THEY WILL NOT RECEIVE SERVICES.

Are there safety concerns for youth to access services at IFR on 2919 Mission St? Yes No

Please Fax: 415.647.4296 or e-mail at:

1. Referral source will be contacted within 2 business days to discuss service needs and consent to refer.

2. Families will be offered 3 intake opportunities before the referral is “closed” or placed on a waiting list.

Please see back of Referral Form for program descriptions. Program assignment will be based on capacity and eligibility criteria

Instituto Familiar de la Raza, Inc.

2919 Mission Street  San Francisco, CA 94110 415-229-0500 (Office) 415-647-0740(Fax)

La Cultura Cura

Program Description

“Youth for Self-Determination!”

Pro-socialization Groups: Latinas Unidas is a school-based service that provides recently arrived youth with culturally grounded youth-development programming. Referrals must be made by SFUSD staff, youth, or families at the service sites, currently SF International and Mission H.S.’s.

Peace Dialogues provides Leadership Development workshops focused on providing youth with tools to better understand the dynamics that lead to violence and develop tools to become “Peace Ambassadors.” Participants are also provided with outlets for healthy healing including Drumming, arts and crafts activities, and creative expression outlets of choice.

Restorative Case Management (RCM): Violence Prevention Case Management consisting of a minimum of hourly weekly contacts in order to provide linkage and referral services to address youth’s service plan needs. Participants receive a psycho-social assessment to determine individual and family support goals. This service usually ranges from 3-6 months and is targeted for youth who may be engaged in any system of care, with Juvenile Justice Status 300 & 601, or first time 602 offenders. Participants must have No More than 2 “Concerns/Risk Factors/Needs” to be eligible for this service.

Intensive Case Management (ICM): Case management services that consist of a minimum of 3 hours of direct and collateral contacts per week to address client’s service plan needs. This service usually ranges from 6 to 12 months and targets youth who may be at risk for or actively engaged in MULTIPLE systems of care includingthe Juvenile Justice, CPS,and Foster Care System. The youth must presentwith MORE than 2 risk factors to be enrolled in this program. Participants receive an individualized psycho-social assessment and service plan to address areas of need including access to family support services.

Participants Must have 2 or More“Concerns/Risk Factors/Needs” to be eligible for this service.

Trauma Recovery and Healing Services (TRHS): A mental health service for youth andfamilies that have recently experienced a traumatic event as a result of violence. TR&HSprovides short-term mental health interventions and linkages to long-term services for those affected by trauma in the community or are at risk of becoming victims or aggressors. The services consist of individual and family therapy, consultation and debriefingsupport to service providers after a violent or traumatic event, and crisis response services 24-hours after a qualifying event.Preventative psycho-educational support groups for parents and youth are offered periodically for families with a qualifying teenager in our service.

Must have 2 or More“Concerns/Risk Factors/Needs” or experienced a qualifying Traumatic incident to be eligible.

Clinical Case Management (CCM): CM services offered to youth that meet criteria for ICM but require additional treatment support as determined by medical necessity. Participants may be involved with the JJS but not “formal” wards of the court, have legal issues stemming from immigration, or have been referred by a system of care partner including the SFVIP to due “crisis”. LCC Mental Health Specialist’s conduct a CANS assessment to determine diagnosis, individual, and if appropriate, family case management service needs. Depending on the outcome of their individualized assessment youth receive multiple hours of weekly individualized support to address their behavioral health concerns and psycho-social needs.

Must have 2 or More“Concerns/Risk Factors/Needs”And meet Medical Necessity to be eligible for this service.

Intensive Supervision & Clinical Services (ISCS): Case management and Treatment services that providecourt supervision and treatment services to youth on probation. Clients are seen three times a week at home, school, or in the community. A CANS assessment is provided to inform a service plan which is created in conjunction with the youth and family with the purpose of providing support with satisfying their probation guidelines. The case manager attends all court hearings and provides individual progress reports to the court. The Mental Health Specialist provides weekly clinical support to address behavioral health needs. Referrals Must be Submitted by the Carrying Probation Officer