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PFI Referral Form
Referral Date
CLC Firm
SAC1
SAC2
Youth
Dependency Court Case No
First Name
Last Name
Birth Date
Gender
Male
Female
Non-binary
Decline to state
Transgender Status
No
Yes
Decline to state
Race/Ethnicity
Asian
Black/African American/African
Hispanic/Latino
Native American/Alaska Native
Native Hawaiian/Pacific Islander
White/Caucasian
Client Declines to State
Client Does Not Know
Other
Unknown
Preferred Pronouns
he/him/his
she/her/hers
they/them/their
Email
Phone Number
Other Ways to Reach Youth
Living Situation
Away from Care/AWOL
Homelessn/Unhoused
Shelter
Substance Abuse Treatment Facility
Residential Treatment Center
Home with One Biological Parent
Home with Both Biological Parents
Home of Relative
Home with NREFM
Medical Hospital
Psychiatric Hospital
DDMI
DCFS Foster Home
FFA Foster Home
STRTP
STRTP - EPY
Juvenile Hall
Probation Suitable Placement
Probation Camp
Secure Treatment Facility (SYTF)
Regional Center Home
Transitional Housing
Supervised Independent Living (SILP)
NMD not in placement
NMD not in approved SILP
Jail
Other
Street Address
City
State/Province
- None -
Postal Code
Specific Caretaker Type
Biological Parent
Caregiver/Guardian
Placement Staff
Individual Name
Relationship to Youth
Phone
Expecting and Parenting
This client is a
- Select -
Minor EPY
NMD EPY
EPY Status
No
Expecting
Parent
Expecting and Parent
How many weeks along is the pregnancy?
How many children does the client have?
Dependency Contact Information
Dependency Supervising Attorney Name
Dependency Attorney Name
DCFAS CSW Name
DCFAS CSW Phone
DCFAS CSW Email
Additional CLC Information
Is there a companion case?
- Select -
No
Yes
Name of Clients
Is there a conflict history?
- Select -
No
Yes
Conflict CLC Firm
SAC1
SAC2
Conflict Case Number
Explanation for Conflict
Relationship with another CLC client
Any additional concerns or issues?
substance abuse
mental health
developmental functioning
domestic violence
housing instability
economic instability
CSEC
lack of social/emotional support
co-parenting concerns
general parenting
Other
Please provide a short summary of youth’s situation and reasons why PFI services may be helpful.
Open Case
Case Start Date
Case Type
PFI
Case Status
- Automatic -
Active
Closed
Medium
In Person
Phone
Email
Fax
Letter Mail
Case Subject
Assign Primary Support
- None Found -
Internal Notes
