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Foster Care Assessment Program
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FCAP Referral Form

FCAP Referral Form

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For more information about this program, visit our website at http://fcaponline.org or contact the FCAP by phone (206)744-1617 or email fcap@uw.edu.
Date*
MM slash DD slash YYYY
What type of service are you requesting?*
- Consultation
- Assessment
- Consultation & Assessment
A) Consultation (Virtual)
Will be scheduled within one week
Please send the following after completing this referral for a consultation:
- Current Court Report
B) Assessment
Please send the following after completing the referral for an assessment:
- Current Court Report
- FCAP Release of Information for child/youth signed by the Caseworker
- If youth is 13 years or older, FCAP Release of Information for youth signed by youth as well
- If reunification is being considered, DCYF Release of Information signed by parent(s) being considered
Assessment Eligibility and Criteria
Each Assessment referral must meet eligibility criteria for either a Standard Assessment or a Comprehensive Assessment before it can be accepted. Please determine which criteria are met and check the appropriate boxes. Check all that apply in both sections.
Standard Assessment*
One or more of the following factors must be met
- Placement instability due to emotional/behavioral problems of the child
- More than eighteen months spent in out-of-home care
- Disagreement about appropriate treatment for emotional, behavior, or educational problems
- Uncertainty about the suitability of a caregiver as a permanency resource or disagreement about which of two or more placement options should be chosen
- Reunification is a primary plan but the progress of one or both parents is questioned
- The child or siblings have been the subject of one or more prior dependenices
Comprehensive Assessment*
Two or more of the following factors must be met
- Multiple out-of-home placements
- Chronic behavioral, emotional, physical, or educational problems
- More than two years spent in out-of-home care
- Assessments and evaluations have been completed, but recommendations differ as to the service plan delivery and the best treament and placement options are unknown
- Child or youth is prescribed five or more psychotropic medications or any antipsychotic medications
- Repetitive criminal acts or offenses by the child (including inability to comply with court order, treatment, or with conditions of probation or parole)
- The child has been or is returning to care subsequent to a disrupted or dissolved adoption
Reunification is a primary permanency plan but cannot proceed due to
- One or both parents have made minimal or no progress
- Parents have borderline capabilities with regard to caring for an exceptional needs child. An assessment will assist with determening whether the abilities match the needs
- A successful reunification is highly unlikely, due to intractable problems with the parents, but ground for termination are not present
- Parents are partially or wholly compliant with services, but concerns remain about their capability
- The family has been subject of one or more prior dependencies
FCAP is able to access FamLink to review records. However, if the case is restricted we will need your assistance, as records review is essential to completing the FCAP assessment
- This case is restricted. DCYF Supervisor will arrange view only access for FCAP
C) DCYF Information
DCYF Region*
DCYF Field Office*
Caseworker's First & Last Name*
Caseworker's Email Address*
Caseworker's Phone Number*
Supervisor's First & Last Name*
Supervisor's Email Address*
D) Child Information
DCYF Case ID*
How many children are being referred?*
Child Name #1*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
Please describe race if you selected "multiracial" or "another race". Type N/A if not.*
Gender*
DCYF Person ID*
Legally Free*
- Yes
- No
Date Child Came Into Care*
MM slash DD slash YYYY
Date of Dependency*
MM slash DD slash YYYY
Number of Placements*
Permanent Plan*
Child Name #2*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
Please describe race if you selected "multiracial" or "another race". Type N/A if not.*
Gender*
DCYF Person ID*
Legally Free*
- Yes
- No
Date Child Came Into Care*
MM slash DD slash YYYY
Date of Dependency*
MM slash DD slash YYYY
Number of Placements*
Permanent Plan*
Child Name #3*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
Please describe race if you selected "multiracial" or "another race". Type N/A if not.*
Gender*
DCYF Person ID*
Legally Free*
- Yes
- No
Date Child Came Into Care*
MM slash DD slash YYYY
Date of Dependency*
MM slash DD slash YYYY
Number of Placements*
Permanent Plan*
Child Name #4*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
Please describe race if you selected "multiracial" or "another race". Type N/A if not.*
Gender*
DCYF Person ID*
Legally Free*
- Yes
- No
Date Child Came Into Care*
MM slash DD slash YYYY
Date of Dependency*
MM slash DD slash YYYY
Number of Placements*
Permanent Plan*
Child Name #5*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
Please describe race if you selected "multiracial" or "another race". Type N/A if not.*
Gender*
DCYF Person ID*
Legally Free*
- Yes
- No
Date Child Came Into Care*
MM slash DD slash YYYY
Date of Dependency*
MM slash DD slash YYYY
Number of Placements*
Permanent Plan*
Child Name #6*
First Last
Date of Birth*
MM slash DD slash YYYY
Race*
Please describe race if you selected "multiracial" or "another race". Type N/A if not.*
Gender*
DCYF Person ID*
Legally Free*
- Yes
- No
Date Child Came Into Care*
MM slash DD slash YYYY
Date of Dependency*
MM slash DD slash YYYY
Number of Placements*
Permanent Plan*
E) Consultation Questions
Please note the questions for FCAP to address in a brief consultation. Please read below for more information.*
Consults are a 45-minute service focused on supporting a path towards permanency and linking children and families with the most appropriate services. Examples of how consultations are helpful: assisting with behavior management strategies to avoid placement disruption or school suspension, using visitation to assess and accomplish goals (parent-child bonding, parenting skills, safety), and evidence-based service planning to inform services and interventions.

F) Assessment Needs
Questions for FCAP to address regarding permanency and well-being
G) Placement Information
Current Caregiver Name (Child Number #1)*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
The caregiver(s) have been informed of this referral?
- Yes
- No
Current Caregiver Name (Child #2)*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
The caregiver(s) have been informed of this referral?
- Yes
- No
Current Caregiver Name (Child #3)*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
The caregiver(s) have been informed of this referral?
- Yes
- No
Current Caregiver Name (Child #4)*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
The caregiver(s) have been informed of this referral?
- Yes
- No
Current Caregiver Name (Child #5)*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
The caregiver(s) have been informed of this referral?
- Yes
- No
Current Caregiver Name (Child #6)*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
The caregiver(s) have been informed of this referral?
- Yes
- No
H) School Information
School Name Child #1*
Teacher's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
School Name Child #2*
Teacher's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
School Name Child #3*
Teacher's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
School Name Child #4*
Teacher's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
School Name Child #5*
Teacher's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
School Name Child #6*
Teacher's Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email

I) Parents
How many parents are involved?*
Parent 1 Name*
First Last
Are parental rights terminated?*
- Yes
- No
Address, skip if parental rights are terminated.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone, skip if parental rights are terminated.
Email, skip if parental rights are terminated.
The parents have been informed of this referral?*
- Yes
- No
Parent 2 Name*
First Last
Are parental rights terminated?*
- Yes
- No
Address, skip if parental rights are terminated.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone, skip if parental rights are terminated.
Email, skip if parental rights are terminated.
The parents have been informed of this referral?*
- Yes
- No
Parent 3 Name*
First Last
Are parental rights terminated?*
- Yes
- No
Address, skip if parental rights are terminated.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone, skip if parental rights are terminated.
Email, skip if parental rights are terminated.
The parents have been informed of this referral?*
- Yes
- No

Parent's Attorney Information
Skip if parental rights are terminated.
Parent #1 Attorney's Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Parents' attorneys aware of this referral?*
- Yes
- No
- N/A
Parent #2 Attorney's Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Parents' attorneys aware of this referral?*
- Yes
- No
- N/A
Parent #3 Attorney's Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Parents' attorneys aware of this referral?*
- Yes
- No
- N/A
OPD Social Worker
Skip if parental rights are terminated.
Parent #1's OPD Social Worker
First Last
Phone
Email
Parent #2's OPD Social Worker
First Last
Phone
Email
Parent #3's OPD Social Worker
First Last
Phone
Email

J) CASA/GAL Information (skip if child isn't assigned to CASA)
CASA/GAL Name Child #1
First Last
CASA/GAL Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CASA/GAL Phone
CASA/GAL Email
CASA/GAL Name Child #2
First Last
CASA/GAL Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CASA/GAL Phone
CASA/GAL Email
CASA/GAL Name Child #3
First Last
CASA/GAL Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CASA/GAL Phone
CASA/GAL Email
CASA/GAL Name Child #4
First Last
CASA/GAL Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CASA/GAL Phone
CASA/GAL Email
CASA/GAL Name Child #5
First Last
CASA/GAL Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CASA/GAL Phone
CASA/GAL Email
CASA/GAL Name Child #6
First Last
CASA/GAL Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
CASA/GAL Phone
CASA/GAL Email
Child's Attorney Information (skip if child doesn't have an attorney)
Attorney's Name Child #1
First Last
Child's Attorney Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Attorney Phone
Child's Attorney Email
Attorney's Name Child #2
First Last
Child's Attorney Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Attorney Phone
Child's Attorney Email
Attorney's Name Child #3
First Last
Child's Attorney Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Attorney Phone
Child's Attorney Email
Attorney's Name Child #4
First Last
Child's Attorney Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Attorney Phone
Child's Attorney Email
Attorney's Name Child #5
First Last
Child's Attorney Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Attorney Phone
Child's Attorney Email
Attorney's Name Child #6
First Last
Child's Attorney Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Child's Attorney Phone
Child's Attorney Email

K) Service Providers
Please identify the primary service providers for the child, caregivers, or family
How many service providers are involved?*
Service Provider 1*
First Last
Agency*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email*
Service provided and for whom:*
Service Provider 2 Name*
First Last
Agency*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Services provided and for whom*
Service Provider 3 Name*
First Last
Agency*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Services provided and for whom*
Service Provider 4 Name*
First Last
Agency*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Services provided and for whom*

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