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:	#1:	#2:
Time:
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
Placement Needs (Initial/Change of Placement)
Placement Preservation Strategy	Yes No
Pathways to Well-Being – Eligible for Enhanced Services	Yes No
Behavioral Health Treatment Needs (i.e., mental health, substance use disorders)
GH/STRTP/RTF Placement Review (every 90 days)
Assess appropriateness for Voluntary Services
End of Voluntary Out of Home Case Plan
Family Maintenance/Voluntary Services case planning/teaming
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, placement preservation strategy to conserve placement, etc.):

Focus Child(ren)
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):
Behavioral Health Concerns i.e., mental health, substance use disorders (Specify):
Domestic Violence:
Current Restraining Order (between which parties?):
NOTE: Please submit a separate CFT Meeting referral form for each parent if there is a current restraining order between them.
Alleged Perpetrator of Sexual Abuse (Specify):

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 ages 16+
Emergency RFA Worker
Additional Support / Relationship
Additional Support / Relationship
Additional Support / Relationship
Additional Support / Relationship

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 (08/21)	Page 2 of 3	County of San Diego/HHSA/PSG

04-444 (08/21)	Page 3 of 3	County of San Diego/HHSA/PSG

04-444 (08/21)	Page 1 of 3	County of San Diego/HHSA/PSG

Jerelyn Bourdage

2021-08-11

Elizarraraz-Lopez, Nancy

The County of San Diego