CAFES Referral Form

"*" indicates required fields

Email*

A copy of your responses will be emailed to the address you provided.

Referring attorney's name*

First Middle Last

Referring attorney's email*

Referring attorney's phone*

How would you like your CAFES to contact/update you?

Via phone

Via text

Via email

Face-to-face

Other:

How would you like your CAFES to contact/update you?

Referred case name:*

JD number:*

Department:*

405

406

425

Identified client's name:*

First Middle Last

Identified client's address

Identified client's phone number

Identified client's email

Age of dependent(s)

Client:

Mother

Father

Minor(s)

Non minor dependent (NMD)

Legal guardian

De facto parent

Referred client's race (select all that apply):

Black/African American

American Indian or Alaska Native

Asian

Hawaiian or other Pacific Islander

White

Hispanic/Latino

Unknown or not disclosed

Other:

Referred client's race (select all that apply):

Client's first language spoken:

English

Spanish

Mandarin

Cantonese

Tagalog

Vietnamese

Arabic

Russian

Other:

Client's first language spoken:

Petition date:

MM slash DD slash YYYY

Dependency petition allegations about the parent:

Physical abuse

Sexual abuse

General neglect

Mental health

Substance abuse

Emotional abuse/other safety concerns

Current phase of proceedings:

Pre-Jurisdiction/disposition

Disposition to 6-month review

6-month to 12-month review

12-month to 18-month review

Family Maintenance

Non Minor Dependent (NMD)

Other:

Current phase of proceedings:

Returning case?

There has been a previous dependency case filed on this child

There has been a previous dependency case filed on a sibling

Non minor dependent seeking reentry

Failed guardianship

Failed adoption

No prior history

Other:

Returning case?

Is the client currently a participant of FTC?

Yes

Referral pending

Prior CPS history/allegations:

Current FCS PSW (protective service worker) name:

Current FCS PSW (protective service worker) number:

Current placement type for the child/ren:

In home

Relative provider

Foster Family Agency (FFA)

City and county foster home

Therapeutic foster home

Residential treatment

Short term residential treatment program (STRTP)

High level/locked facility

Fost-Adopt home

Unknown

Other:

Current placement type for the child/ren:

County of current placement for the child/ren:

San Francisco

Alameda

Contra Costa

Marin

Sonoma

Napa

Stanislaus

San Mateo

San Joaquin

Sacramento

Fresno

Other:

County of current placement for the child/ren:

Number of placements for the child/ren:

5-10

10+

Current school/s attended by the child/ren or N/A:

Educational support needed for the child/ren?

IEP (in place or assessment needed)

504 (in place or assessment needed)

Educational rights (assistance needed)

Credit recovery assistance needed

School of origin issue

Assist parent in advocating for child's educational rights

N/A

Other:

Educational support needed for the child/ren?

Your client's mental health concerns:

Client diagnosed (ie. bipolar, schizophrenia, PTSD, ADHD, etc.)

Client needs an assessment (psych eval, CANS, regional, or other)

Current symptoms but no history

No symptoms or history or N/A

Client in therapy

Other:

Your client's mental health concerns:

Your clients substance abuse concerns:

Needs referral for residential or outpatient treatment

Currently participating in residential treatment

Currently participating in outpatient treatment

History/signs of abuse, needs assessment

History of sobriety or N/A

Involved in Family Treatment Court (FTC)

Open case in homeless prenatal program (HPP)

Other:

Your clients substance abuse concerns:

Parenting education for your client:

Completed program

Partial completion of program

Needs assistance with referral

N/A

Domestic violence history for your client:

Client was a victim

Client was a perpetrator

Minor/s witnessed domestic violence

Client has received DV assessment

Client needs DV assessment and/or treatment

Client currently attending DV treatment program

N/A

Other

Domestic violence history for your client:

Ancillary legal issues for your client:

Adult criminal case open (DUI, physical abuse, sexual abuse, drug possession, etc.)

Delinquency case open

Immigration

Restraining order

N/A

Other:

Ancillary legal issues for your client:

Current visitation for your client:

Therapeutic

Supervised

Monitored

Unsupervised

Visitation for the child is needed:

With mother

With father

With siblings

With relatives

Issues with getting face to face visits

N/A

Other

Visitation for the child is needed:

Case goals:

Assist in communication between client-attorney and client-department

Identifying appropriate service providers- advocating for best match possible

Visitation- advocating for less restrictive/face to face

Housing- locating programs for client to make self referral

Incarcerated parent- encouraging participation and appropriate contact

Advocacy for transportation to necessary appointments and visits

Child welfare system navigation and explaining court process

Advocacy to assist dependency litigation

Intimate partner violence- encouraging clients to complete program

Termination pending- support family in understanding process

Case planning- support client in completing case plan and advocating for changes when warranted

Permanency- assist minors with finding permanency/family finding

Assist in formulating recommendations (ie. mental health issues, SOP questions, etc.)

Assist attorneys in highlighting lack of reasonable efforts made by HSA

Attend any collaborative meetings to advocate for client's needs (ie. CFTs, mediation, etc.)

Assist in school meetings/IEPs/educational support

Assist client in case plan compliance

Develop legal strategy for case

Assessing/analyzing therapeutic needs of minor and advocating for treatment

Assist client/s in LGBTQ issues

Assist attorneys in assessing competency/cognitive, and unaddressed mental health issues

Assist attorney by completing F/F visit/s with client/s to gather information and assess needs

Other:

Case goals:

Having a CAFES for a client is voluntary and should have the client's full agreement PRIOR to making the referral. My client agreed to being assigned a CAFES:

Yes

I still need to discuss with them

Summary of current concerns and specific objectives that you would like addressed. Include any urgent needs with deadlines, and what you think needs to be prioritized.

Next court date/type of hearing:

Do you have any preferences that you think would be a good fit for this case? (eg. race, gender, name(s), expertise of who might be the best fit for this parent)

**This selection is NOT guaranteed. We will do our best to accommodate preferences/best fit.**

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