Form CFS912 "Referral Form" - Illinois

What Is Form CFS912?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CFS912 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form CFS912 "Referral Form" - Illinois

Download PDF

Fill PDF online

Rate (4.6 / 5) 52 votes
CFS 912
State of Illinois
Rev. 9/2020
Department of Children and Family Services
Referral Form
Please check one Referral type and include two copies of all requested documents.
Life Skills (Youth in foster care, 14 to 21 Years of Age)
Referral Packets shall include two copies of the following documents:
CFS 912, Referral Form (All requested information must be entered on the
completed form.);
Face sheet and child specific section of current SACWIS service plan;
Integrated Assessment;
scored Casey Life Skills Assessment
CFS 600-3, Consent for Release of Information, signed by the youth and/or
authorized agent of the Guardianship Administrator.
Financial Literacy Education
(Youth in DCFS managed placement, within 30 days of
attaining 19 years of age)
Referral Packets shall include two copies of the following documents:
CFS 912, Referral Form (All requested information must be entered on the
completed form.);
CFS 600-3, Consent for Release of Information, signed by the youth and/or
authorized agent of the Guardianship Administrator.
Completed referral packets must be submitted to the appropriate Transition Manager of the Office of
Education and Transition Services (OETS). Please do not fax life skills referrals.
OETS TRANSITION MANAGERS
Cook Region
Northern Region
Central & Southern Region
OETS Transition Manager
OETS Transition Manager
OETS Transition Manager
DCFS
DCFS
DCFS
6201 S. Emerald Drive
8 E. Galena Blvd., Suite 300
2309 W. Main Street, Suite 108
Chicago, Illinois 60621
Aurora, Illinois 60506
Marion, Illinois 62959
630-801-3446
618-993-7100
773-371-6423
CASEMANAGER DATA
Date:
Name of DCFS/POS Worker:
Worker’s R/S/F:
Worker’s e-mail address:
Worker’s Agency:
Worker’s Address (Street, City, State & Zip):
Telephone: (
)
-
Facsimile: (
)
-
Supervisor’s Name:
Telephone: (
)
-
YOUTH DATA
Youth’s Name:
DOB:
Age:
DCFS ID:
Telephone: (
)
-
Cell phone: (
)
-
Youth’s Address (Street, City, State & Zip):
Youth’s email address:
County:
Youth’s signature:
(1)
CFS 912
State of Illinois
Rev. 9/2020
Department of Children and Family Services
Referral Form
Please check one Referral type and include two copies of all requested documents.
Life Skills (Youth in foster care, 14 to 21 Years of Age)
Referral Packets shall include two copies of the following documents:
CFS 912, Referral Form (All requested information must be entered on the
completed form.);
Face sheet and child specific section of current SACWIS service plan;
Integrated Assessment;
scored Casey Life Skills Assessment
CFS 600-3, Consent for Release of Information, signed by the youth and/or
authorized agent of the Guardianship Administrator.
Financial Literacy Education
(Youth in DCFS managed placement, within 30 days of
attaining 19 years of age)
Referral Packets shall include two copies of the following documents:
CFS 912, Referral Form (All requested information must be entered on the
completed form.);
CFS 600-3, Consent for Release of Information, signed by the youth and/or
authorized agent of the Guardianship Administrator.
Completed referral packets must be submitted to the appropriate Transition Manager of the Office of
Education and Transition Services (OETS). Please do not fax life skills referrals.
OETS TRANSITION MANAGERS
Cook Region
Northern Region
Central & Southern Region
OETS Transition Manager
OETS Transition Manager
OETS Transition Manager
DCFS
DCFS
DCFS
6201 S. Emerald Drive
8 E. Galena Blvd., Suite 300
2309 W. Main Street, Suite 108
Chicago, Illinois 60621
Aurora, Illinois 60506
Marion, Illinois 62959
630-801-3446
618-993-7100
773-371-6423
CASEMANAGER DATA
Date:
Name of DCFS/POS Worker:
Worker’s R/S/F:
Worker’s e-mail address:
Worker’s Agency:
Worker’s Address (Street, City, State & Zip):
Telephone: (
)
-
Facsimile: (
)
-
Supervisor’s Name:
Telephone: (
)
-
YOUTH DATA
Youth’s Name:
DOB:
Age:
DCFS ID:
Telephone: (
)
-
Cell phone: (
)
-
Youth’s Address (Street, City, State & Zip):
Youth’s email address:
County:
Youth’s signature:
(1)
CFS 912
Rev. 9/2020
PLACEMENT DATA
Contact Name:
Relationship:
Address (Street, City, State & Zip):
Work or Message Telephone: (
)
-
Home Telephone: (
)
-
Email address:
Describe any safety related concerns.
Are there any transportation issues? How will the youth get to classes?
When is the youth available to participate in classes (i.e., Wednesday evenings, Saturday mornings)?
Does the youth have any behavioral/emotional problems? Include clinical diagnosis and medications, if
applicable.
What is the youth’s learning style?
Auditory
Visual
Participatory
Does the youth have a physical disability?
Yes
No
Type of disability:
Date Received:
Approved:
Yes
No
Pended:
Yes
No
Date
Date
Assigned Provider:
Signature of Transition Manager:
(2)
Page of 2