FCAP Referral Form FCAP Consultation and Assessment Referral Form "*" indicates required fields Date:* MM slash DD slash YYYY What type of service are you requesting?* Consultation Assessment Consultation & Assessment FCAP Services and Eligibility CriteriaAll children or youth must meet the referral and eligibility criteria to be considered for either a Standard or Comprehensive Assessment. Children or youth who have received an FCAP Assessment within the previous eighteen (18) months are not eligible to receive another assessment. Our FCAP services and eligibility have been slightly updated. Please review the summaries below. Consultations are 45 minute phone or video conversations between the FCAP evaluator and DCYF caseworker to address a specific question. In order for your referral to be considered complete the most recent court report is required and can be uploaded below. Standard assessments will address one or two issues of concern below and will be completed within 28 days of assignment. Children must have been in out-of-home care for 18 months. Comprehensive assessments will address three or more issues of concern below and will be completed within 56 days of assignment. Reserved for the most complex cases. Children must have been in out-of-home care for 2 years. ISSUES OF CONCERNCheck the appropriate box(es) below: Child or youth presents with chronic behavioral, emotional, physical, or academic needs. Completed assessments differ as to the service plan delivery, best treatment options, or placement options are unknown. The child or youth has been involved in repetitive criminal acts or offenses. The child or youth has been the subject of one or more prior dependencies. The child or youth has returned to an out-of-home placement after a disrupted or dissolved guardianship or adoption. There is a difference of opinion about: Appropriate treatment for behavioral, emotional, or academic needs. One or more placement options. The suitability of a caregiver as a permanent placement. Reunification is a primary permanency plan, but cannot proceed due to: Minimal to no parent or guardian progress. Concerns whether the parent or guardians have the skills to care for the exceptional needs of the child or the youth. An assessment will assist with determining whether their skills match the child or youth’s needs. Successful reunification is highly unlikely, but the grounds for termination of parental rights are not present. Parents or guardians are partially of fully compliant with services, but concerns remain about their ability to parent or they have their own unmet needs. Consultation-Briefly note the question about permanency or well-being to be discussed in the consultation.*Assessment -Please note the specific question from the issues of concern noted above.*Documents REQUIRED for a consultation:* Most recent court report for each child. Documents REQUIRED for either assessment:* Most recent court report for each child. FCAP authorization form signed by DCYF case worker for children 12 and younger. DCYF ROI signed by youth 13 years or older. DCYF ROI for parents if reunification is being considered. Upload Current Court Report* Drop files here or Select files Max. file size: 50 MB. Upload Signed FCAP Authorization Form & Release of Information (assessments only)* Drop files here or Select files Max. file size: 50 MB. Is this referral court-ordered?* Yes No A. DCYF INFORMATIONDCYF Region:*Please chose a regionRegion 1Region 2Region 3Region 4Region 5Region 6DCYF Office:*Please chose a DCYF officeAberdeenBellinghamBremertonClarkstonColfaxColvilleEllensburgEverettForksFriday HarborGoldendaleKelsoKing East (Bellevue)King Southeast (Kent)King Southwest (Kent)King WestLakewoodLong BeachLynnwoodMLK Jr.Moses LakeMount VernonNewportOak HarborOffice of Indian Child Welfare (ICW)OmakParklandPort AngelesPort TownsendPuyallupSheltonSky Valley (Monroe)Smokey PointSpokane CentralSpokane ICWSpokane NorthSpokane ValleyStevensonSunnysideTacomaToppenishTri-CitiesTumwater-DeschutesTumwater-RainierVancouver CascadeVancouver ColumbiaWalla WallaWenatcheeWest SeattleWhite SalmonYakimaCaseworker First & Last Name:*Caseworker Phone Number:*Caseworker Email:*Supervisor First & Last Name:*Supervisor Email:* B. CHILD INFORMATIONDCYF Case ID:*FCAP evaluators have access to FAMLINK to review records. However, if the case is restricted we will need your assistance. This case is restricted. DCYF supervisor will arrange view only access for FCAP. Number of children referred:*123456Child #1 Name:* First Last Date of Birth:* MM slash DD slash YYYY DCYF Person ID:*Gender:*Please select a genderMaleFemaleTransgenderGender NobinaryGender FluidGender QueerIntersexAgenderBigenderDemiboyDemigirlTwo SpiritRace:*Please select a raceAlaska NativeAnother RaceBlack/African AmericanLatinX/Latino/Latina/HispanicMultiracialNative American IndianNative HawaiianPacific IslanderWhitePlease describe race is you checked "multiracial" or "another race".Hispanic?* 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:*ReunificationAdoptionGuardianshipThird Party CustodyLegally free?* Yes No Child #2 Name:* First Last Date of Birth:* MM slash DD slash YYYY DCYF Person ID:*Gender:*Please select a genderMaleFemaleTransgenderGender NobinaryGender FluidGender QueerIntersexAgenderBigenderDemiboyDemigirlTwo SpiritRace:*Please select a raceAlaska NativeAnother RaceBlack/African AmericanLatinX/Latino/Latina/HispanicMultiracialNative American IndianNative HawaiianPacific IslanderWhitePlease describe race is you checked "multiracial" or "another race".Hispanic?* 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:*ReunificationAdoptionGuardianshipThird Party CustodyLegally free?* Yes No Child #3 Name:* First Last Date of Birth:* MM slash DD slash YYYY DCYF Person ID:*Gender:*Please select a genderMaleFemaleTransgenderGender NobinaryGender FluidGender QueerIntersexAgenderBigenderDemiboyDemigirlTwo SpiritRace:*Please select a raceAlaska NativeAnother RaceBlack/African AmericanLatinX/Latino/Latina/HispanicMultiracialNative American IndianNative HawaiianPacific IslanderWhitePlease describe race is you checked "multiracial" or "another race".Hispanic?* 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:*ReunificationAdoptionGuardianshipThird Party CustodyLegally free?* Yes No Child #4 Name:* First Last Date of Birth:* MM slash DD slash YYYY DCYF Person ID:*Gender:*Please select a genderMaleFemaleTransgenderGender NobinaryGender FluidGender QueerIntersexAgenderBigenderDemiboyDemigirlTwo SpiritRace:*Please select a raceAlaska NativeAnother RaceBlack/African AmericanLatinX/Latino/Latina/HispanicMultiracialNative American IndianNative HawaiianPacific IslanderWhitePlease describe race is you checked "multiracial" or "another race".Hispanic?* 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:*ReunificationAdoptionGuardianshipThird Party CustodyLegally free?* Yes No Child #5 Name:* First Last Date of Birth:* MM slash DD slash YYYY DCYF Person ID:*Gender:*Please select a genderMaleFemaleTransgenderGender NobinaryGender FluidGender QueerIntersexAgenderBigenderDemiboyDemigirlTwo SpiritRace:*Please select a raceAlaska NativeAnother RaceBlack/African AmericanLatinX/Latino/Latina/HispanicMultiracialNative American IndianNative HawaiianPacific IslanderWhitePlease describe race is you checked "multiracial" or "another race".Hispanic?* 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:*ReunificationAdoptionGuardianshipThird Party CustodyLegally free?* Yes No Child #6 Name:* First Last Date of Birth:* MM slash DD slash YYYY DCYF Person ID:*Gender:*Please select a genderMaleFemaleTransgenderGender NobinaryGender FluidGender QueerIntersexAgenderBigenderDemiboyDemigirlTwo SpiritRace:*Please select a raceAlaska NativeAnother RaceBlack/African AmericanLatinX/Latino/Latina/HispanicMultiracialNative American IndianNative HawaiianPacific IslanderWhitePlease describe race is you checked "multiracial" or "another race".Hispanic?* 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:*ReunificationAdoptionGuardianshipThird Party CustodyLegally free?* Yes No C. PLACEMENT INFORMATIONCurrent Caregiver (Child #1):* First Last Phone:*Email:* Have the caregivers been notified of the referral?* Yes No Current Caregiver (Child #2):* First Last Phone:*Email:* Have the caregivers been notified of the referral?* Yes No Current Caregiver (Child #3):* First Last Phone:*Email:* Have the caregivers been notified of the referral?* Yes No Current Caregiver (Child #4):* First Last Phone:*Email:* Have the caregivers been notified of the referral?* Yes No Current Caregiver (Child #5):* First Last Phone:*Email:* Have the caregivers been notified of the referral?* Yes No Current Caregiver (Child #6):* First Last Phone:*Email:* Have the caregivers been notified of the referral?* Yes No D. SCHOOL INFORMATIONSchool Name (Child #1):*Teacher First & Last Name:Email: School Name (Child #2):*Teacher First & Last Name:Email: School Name (Child #3):*Teacher First & Last Name:Email: School Name (Child #4):*Teacher First & Last Name:Email: School Name (Child #5)*Teacher First & Last Name:Email: School Name (Child #6):*Teacher First & Last Name:Email: E. PARENTSHow many parents are invloved?*1234First & Last Name (Parent #1): First Last Are parental rights terminated? If yes, skip this section.* Yes No Phone, skip if parental rights are terminatedEmail, skip if parental rights are terminated Has the parent been informed of this referral? (Skip if parental rights are terminated) Yes No Attorney First & Last Name (Parent #1), skip if parental rights are termiantedPhone:Email:Has the parents attorney been notified of this referral? Skip if parental rights have been terminated Yes No First & Last Name (Parent #2): First Last Are parental rights terminated ?* Yes No Phone, skip if parental rights are terminatedEmail, skip if parental rights are terminated Have the parent been informed of this referral? (Skip if parental rights are terminated) Yes No Attorney First & Last Name (Parent #2), skip if parental rights are terminatedPhone:Email:Has the parents attorney been notified of this referral? (Skip if parental rights have been terminated) Yes No First & Last Name (Parent #3): First Last Are parental rights terminated ?* Yes No Phone, skip if parental rights are terminatedEmail, skip if parental rights are terminated Have the parent been informed of this referral? (Skip if parental rights are terminated) Yes No Attorney First & Last Name, skip if parental rights have been terminatedPhone:Email:Has the parents attorney been notified of this referral? (Skip if parental rights are terminated) Yes No Parent #4 First & Last Name: First Last Are parental rights terminated ?* Yes No Phone,skip if parental rights are terminatedEmail, skip if parental rights are terminated Have the parent been informed of this referral? (Skip if parental rights are terminated) Yes No Parent #4 Attorney First & Last Name, skip if parental rights are terminatedPhone:Email:Has the parents attorney been notified of this referral? (Skip if parental rights are terminated) Yes No F. CASA/GAL Information (skip if the child is not assigned a CASA)CASA/GAL (Child #1): First Last Phone:Email: CASA/GAL(Child #2): First Last Phone:Email: CASA/GAL (Child #3): First Last Phone:Email: CASA/GAL (Child #4): First Last Phone:Email: CASA/GAL (Child #5): First Last Phone:Email: CASA/GAL (Child #6): First Last Phone:Email: G. Child Attorney (skip if the child does not have an attorney)Attorney (Child #1): First Last Phone:Email: Attorney (Child #2): First Last Phone:Email: Attorney (Child #3): First Last Phone:Email: Attorney (Child #4): First Last Phone:Email: Attorney (Child #5): First Last Phone:Email: Attorney (Child #6): First Last Phone:Email: H. SERVICE PROVIDERSPlease identify the primary services providers for the child, caregiver or family.How may service providers are involved:*01234Provider #1 Name: First Last Agency:Phone:Email: Service provided for whom?Provider #2 Name: First Last Agency:Phone:Email: Service provided for whom?Provider #3 Name: First Last Phone:Email:Service provided for whom?Provider #4 Name: First Last Agency:Phone:Email:Service provided for whom?Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Δ
