Iowa Department of HUman SErvices Family Foster Care Referral

/

Referral Information

Date: / Referral Time: / Enhanced Referral: Yes No

Referring Worker

Name: / Email: / Phone:
City: / County: / Cell Phone:

Referring worker Supervisor Information

Supervisor Name:
Email: / Cell Phone:
FSRP Care Coordinator Information
Name:
Email: / Cell Phone:

Child Information at time of removal

Name:
Date of birth: / State ID: / Language:
ICWA: Yes No / Male Female / Race:
Current address:
City: / State: / ZIP Code:
Financial County: / Previous Placement: Yes No /

Child Drives Self: Yes No

School District: / Current School: / Grade:
IEP? Yes No / Behavioral Educational / Special Education : Yes No
Attends Church: Yes No / Does Child Identify as LGBTQ ? Yes No / Sexually Active : Yes No

If Enhanced Referral Name of Placement and any applicable services to help with transition:

Discussion of Childs’ Strengths and Needs:

Child’s special interest or activities:

Does Child have Siblings that will require continued contact? Yes No

Child’s Birth Family Information (If different from child address above due to previous placement)

Address:
City: / State: / ZIP Code: / County:
Adjudication: Yes No / Anticipated Length of Care:
Is the Child being Moved From a Foster Placement Yes No / If Yes; Was a Placement Stability Staffing held?
Yes No
How many Foster placements has the child been in?
When is placement needed by (The Time frames can be between 2 hours and 45 Days)?
Reason For Removal:
Use Scale for each section below for those diagnosis that apply. If it does not apply leave it blank.
Scale 2-5:
2. Child may have or has a very mild level of this behavior / special need.
3. Child has a mild / moderate level of this behavior / special need.
4. Child has a moderate / severe level of this behavior / special need.
5. Child has a very severe level of this behavior / special need.
Mental Health Diagnosis / Explanation or discussion of Severity / Scale 2-5
ADHD / Click here to enter text. / If applicable.
Asperger’s Syndrome / Click here to enter text. / If applicable.
Autism / Click here to enter text. / If applicable.
Bi-Polar Disorder / Click here to enter text. / If applicable.
Attachment / Click here to enter text. / If applicable.
Anxiety / Click here to enter text. / If applicable.
Depression / Click here to enter text. / If applicable.
Conduct Disorder / Click here to enter text. / If applicable.
Obsessive-Compulsive / Click here to enter text. / If applicable.
Oppositional Defiance Disorder / Click here to enter text. / If applicable.
Adjustment Disorder / Click here to enter text. / If applicable.
Post-Traumatic Stress Disorder / Click here to enter text. / If applicable.
Intellectual Disability / Click here to enter text. / If applicable.
Serious Behavioral Issues / Explanation or discussion of Severity / Scale 2-5
Destructive behavior towards property / Click here to enter text. / If applicable.
Self-Harming Behavior / Click here to enter text. / If applicable.
Suicide Ideation / Click here to enter text. / If applicable.
Assaultive Behavior / Click here to enter text. / If applicable.
Encopresis or Enuresis Disorders / Click here to enter text. / If applicable.
Fire Setting Behaviors / Click here to enter text. / If applicable.
Pet Abuse/Fear of / Click here to enter text. / If applicable.
Sexually Reactive / Click here to enter text. / If applicable.
Sexual Offender or Perpetrator / Click here to enter text. / If applicable.
Substance or Alcohol Abuse / Click here to enter text. / If applicable.

Iowa Department of HUman SErvices Family Foster Care Referral

/
Physical Health/ Medical Concerns / Explanation or discussion of Severity / Scale2-5
Allergies to Medication / Click here to enter text. / If applicable.
Environmental Allergies / Click here to enter text. / If applicable.
Drug Affected / Click here to enter text. / If applicable.
Fetal Alcohol Syndrome / Click here to enter text. / If applicable.
HIV / Click here to enter text. / If applicable.
Medically Fragile / Click here to enter text. / If applicable.
Physically Challenged / Click here to enter text. / If applicable.
Respiratory Impairment / Click here to enter text. / If applicable.
Special Dietary Needs / Click here to enter text. / If applicable.
Special Medical Needs / Click here to enter text. / If applicable.
Current Formal Information
Formal Diagnosis:
Click here to enter text. / Prescribed Medication and What they are treating
Click here to enter text.
Transportation Needs
School: Yes No Activities: Yes No Healthcare: Yes No
Family Interactions : Yes No Relatives/Friends Yes No Extended Family: Yes No
Other: Yes No Explanation: Click here to enter text.
[Type any additional notes if needed.]
Risk Management
Characteristics of other children that this child should NOT be placed with? Click here to enter text.
What are the characteristics of potential match families you should not consider for this child? Click here to enter text.
Current Service in Place: Click here to enter text.
Search Area? Click here to enter text.
Additional Notes: Click here to enter text.
Form Prepared by: / Click here to enter text. / Date: / Click here to enter a date.

Match Information

Match Family (S):
Match Time: / Date Child(ren) Placed:
Confirmation Date:

Family Foster Care Referral Instructions

Emergency Referral:

If time/circumstances allow, complete and submit the Foster Care Referral form(FCR) to the contractor electronically. Acknowledgement of receipt of the form by the contractor is required to ensure the contractor is aware of the referral.

If time/circumstances do not allow for completion and submittal of the FCR, a referral to the contractor may be initiated verbally. Use the FCR as a tool in preparing to make the verbal referral. Supervisory approval is required to make an Emergency/verbal referral. Document the supervisory approval and rational for approval in the case file.

If additional information becomes available after a verbal referral has been made, provide any additional information to the contractor as it becomes available.

Planned Referral:

The FCR will be completed and submitted to the contractor electronically.

Emergency and Planned Referral:

It is anticipated referring staff and supervisors will be granted review and print access to the contractor data base for their referrals. Once this is confirmed as functional:

1.  Within one business day from acknowledgement of receipt of a referral by the contractor the referral worker will review the information in the data base to ensure all information is accurate and complete.

o If the data base is not complete and accurate, the referral worker will contact the contractor to make any modifications necessary.

o The referral worker will print the information in the data base and place a hard copy in the child case file. I

o f additional information is subsequently provided to the contractor, the referral worker will review the updated information in the data base.

o If the data base is not complete and accurate, the referral worker will contact the contractor to make any modifications necessary,

o The referral worker will print the information in the data base and place a copy in the child case file.

o All printed copies will remain in the child case file.

July 2017 Page 1