Santa Clara County

Social Services Agency

Department of Family and Children’s Services

Differential Response Services Referral

Today’s Date: / Service Provider Assignment:
Path 2 / Path 4 Anticipated Date of Court Dismissal:
Services Recommended:
Case Management / Therapeutic Services / Parent Education/Coaching / Family Partner Support
Case Name: / Case #:
Parent(s)/Legal Guardian(s)/Caregiver(s)
Primary Caregiver: / Relationship: / DOB:
Address: / City: / ZIP:
Home Phone: / Other Phone Contact Number:
Secondary Caregiver: / Relationship: / DOB:
Address: / City: / ZIP:
Home Phone: / Other Phone Contact Number:
Who has legal custody of the child(ren) and what is the arrangement (if known):
Any special instructions when contacting the family:
Best time to reach the family:
Children in the Home
Name: / DOB: / Female Male
Name: / DOB: / Female Male
Name: / DOB: / Female Male
Name: / DOB: / Female Male
Name: / DOB: / Female Male
Name: / DOB: / Female Male
Other People in the Home
Name: / Relationship:
Name: / Relationship:
Other Significant People Outside the Home
Name: / Relationship:
Name: / Relationship:
Family’s Culture and Other Strengths
Primary Family Ethnicity: / Secondary Family Ethnicity:
Primary Family Language: / Secondary Family Language:
Family Strengths:
Current Referral Information
Date of Referral to the CANC:
Primary Referral Allegation:
At risk, sibling abuse / Physical Abuse / Caretaker absence/ Incapacity
Severe Abuse / Emotional Abuse / Sexual Abuse
Exploitation / Substantial Risk / General Neglect
Child Welfare History: / Number of prior CPS referrals: / Prior Dependency: / No Yes
Prior VFM or IS: No Yes
Reason for DR Referral & Current Family Assessment: ( include statements of harm/danger/risk to child; why does the family need DR services; what should the provider focus on )
Services Needed:
Resources/Referrals Parent Ed/Coaching Behavioral Management Therapeutic Services
Housing Transportation DV Resources/Support Substance Abuse Support
Assistance with Basic Needs Other:
Current Services: Current Service Providers/Agencies ( including CalWORKS, Community Agencies ):
Prior Service Received (including DFCS):
Health Insurance: / Medi-Cal Healthy Kids Healthy Families Private
None / Other:
Known Disabilities: / Child: / No Yes / Type: / Adult: / No Yes / Type:
Discussion with Family:
Has the family received Differential Response services in the past? / Yes / No
Is the family willing to participate in Differential Response services? / Yes / No
Participation Scale Level (Circle family’s willingness to participate):
1 2 3 4 5 6 7 8 9 10
Will SW be available for a warm handoff? / Yes / No
Are both parents willing to consent to services? / Yes / No
If not, why?
Alerts/Special Circumstances (i.e. safety concerns, cultural factors, custody orders, etc.):
Social Worker’s Name: / Worker Number:
Phone: / Service Component: / ER DI VFM IS CONT
Supervisor: / Phone:

For assistance, contact the DR Coordinator (408) 501-6415.

Email completed form as an attachment to

SCZ 214A
File: 4th Fastener, Right - Middle / Differential Response Path II & IV Referral – 01/3/2017
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