Form DCF-3001 "Community-Based Life Skills Program (Cbls) Referral Form" - Connecticut

What Is Form DCF-3001?

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

Form Details:

  • Released on December 13, 2016;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • 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 DCF-3001 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-3001 "Community-Based Life Skills Program (Cbls) Referral Form" - Connecticut

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Connecticut Department of Children and Families
COMMUNITY-BASED LIFE SKILLS PROGRAM (CBLS) REFERRAL FORM
DCF-3001
12/13/2016 (New)
Page 1 of 2
NOTE BEFORE COMPLETING THIS REFERRAL FORM: Youth in PASS, TFC, SWETP, TLAP or Group Homes are not eligible for CBLS. Those programs
are required to provide a Life Skills Education Program to the youth residing in their program. Target population for CBLS is DCF-involved youth, age 14 to 21,
residing in an out-of-home placement. Exclusionary criteria include: active psychotic behavior, violent/assaultive behavior or active substance abuse.
CONTACT INFORMATION
Youth's LAST Name:
Youth's FIRST Name:
Date of Referral:
DOB:
Age:
Race:
Ethnicity:
Please Select One
Please Select One
Citizenship status:
Birth Gender:
Current Gender:
Please select one
Victim of Trafficking
Please select one
Prefers to be called / Nickname:
Link
Link CASE ID
Address:
City:
State:
Zip:
Phone #:
Cell Phone #:
E-mail:
DCF Office:
Please Select DCF Office
DCF Worker:
Phone #:
E-mail:
DCF Supervisor:
Phone #:
E-mail:
CBLS Liaison:
Phone #:
E-mail:
LEGAL STATUS
Committed Abuse/Neglect/Uncared for
18 +
Dually Committed
Voluntary Services
Type of Placement:
DCF Foster Home
Relative Foster Home
Therapeutic Foster Home
Residential Facility
Other:
EDUCATION
School Name:
School Contact Person:
Address:
City:
State:
Zip:
Phone #:
Cell Phone #:
E-mail:
Current Educational Concerns, if any:
Long term Education Goals:
Grade:
Grade Level:
College:
After School Activities, if any:
Times
Afterschool Activity Schedule:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
College Prep/accelerated
General Studies
GED
Alternative Learning Program
Vocational/Technical
Special Ed?:
If Yes, please explain:
Current Educational Concerns / Special needs, if any:
Is Youth currently employed?:
Yes
No (Please ensure that the Youth's work schedule does not conflict with the CBLS Schedule)
If Yes, Where?:
Work Schedule:
YOUTH INFORMATION
Youth's Interests:
DSM V Diagnosis:
Youth's medical conditions / allergies (to food, medications or insects:
Please list Medications, if applicable:
Any Special, Relevant Considerations for Educator's to know?:
Provide a brief assessment of the Youth's ability and willingness to participate in this program and in a group setting:
Does the youth have a substance abuse history?
Yes
No
If yes, is the youth
Sober
in Treatment
Actively using
Provide any information regarding obstacles or issues that the youth is currently dealing with, e.g., living situation, behavioral problems or issues, grief,
sexual/gender identity, handicap, illness, etc.
Connecticut Department of Children and Families
COMMUNITY-BASED LIFE SKILLS PROGRAM (CBLS) REFERRAL FORM
DCF-3001
12/13/2016 (New)
Page 1 of 2
NOTE BEFORE COMPLETING THIS REFERRAL FORM: Youth in PASS, TFC, SWETP, TLAP or Group Homes are not eligible for CBLS. Those programs
are required to provide a Life Skills Education Program to the youth residing in their program. Target population for CBLS is DCF-involved youth, age 14 to 21,
residing in an out-of-home placement. Exclusionary criteria include: active psychotic behavior, violent/assaultive behavior or active substance abuse.
CONTACT INFORMATION
Youth's LAST Name:
Youth's FIRST Name:
Date of Referral:
DOB:
Age:
Race:
Ethnicity:
Please Select One
Please Select One
Citizenship status:
Birth Gender:
Current Gender:
Please select one
Victim of Trafficking
Please select one
Prefers to be called / Nickname:
Link
Link CASE ID
Address:
City:
State:
Zip:
Phone #:
Cell Phone #:
E-mail:
DCF Office:
Please Select DCF Office
DCF Worker:
Phone #:
E-mail:
DCF Supervisor:
Phone #:
E-mail:
CBLS Liaison:
Phone #:
E-mail:
LEGAL STATUS
Committed Abuse/Neglect/Uncared for
18 +
Dually Committed
Voluntary Services
Type of Placement:
DCF Foster Home
Relative Foster Home
Therapeutic Foster Home
Residential Facility
Other:
EDUCATION
School Name:
School Contact Person:
Address:
City:
State:
Zip:
Phone #:
Cell Phone #:
E-mail:
Current Educational Concerns, if any:
Long term Education Goals:
Grade:
Grade Level:
College:
After School Activities, if any:
Times
Afterschool Activity Schedule:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
College Prep/accelerated
General Studies
GED
Alternative Learning Program
Vocational/Technical
Special Ed?:
If Yes, please explain:
Current Educational Concerns / Special needs, if any:
Is Youth currently employed?:
Yes
No (Please ensure that the Youth's work schedule does not conflict with the CBLS Schedule)
If Yes, Where?:
Work Schedule:
YOUTH INFORMATION
Youth's Interests:
DSM V Diagnosis:
Youth's medical conditions / allergies (to food, medications or insects:
Please list Medications, if applicable:
Any Special, Relevant Considerations for Educator's to know?:
Provide a brief assessment of the Youth's ability and willingness to participate in this program and in a group setting:
Does the youth have a substance abuse history?
Yes
No
If yes, is the youth
Sober
in Treatment
Actively using
Provide any information regarding obstacles or issues that the youth is currently dealing with, e.g., living situation, behavioral problems or issues, grief,
sexual/gender identity, handicap, illness, etc.
Connecticut Department of Children and Families
COMMUNITY-BASED LIFE SKILLS PROGRAM (CBLS) REFERRAL FORM
DCF-3001
12/13/2016 (New)
Page 2 of 2
Provider (please indicate the name/agency provider if you have a preference)
Recommended Provider Agency Name
Address:
City:
State:
Zip:
Case Manager Name:
Phone #:
E-mail:
Youth may participate in group activities
Yes
No
Has Youth Completed a LIST Assessment?:
Yes
No
If Yes, Please provide the assessment date:
If Yes, Please attach the most current LIST Assessment
Who completed assessment?:
Phone #:
E-mail:
Has youth previously participated in Life Skills?
Yes
No
If Yes, Which?:
Date:
SERVICES AND PROVIDERS (if applicable)
Foster Parent/Placement Contact Name:
Address:
City:
State:
Zip:
Phone #:
Cell Phone #:
E-mail:
CHAP/CHEER Case Management Agency Name (if any):
Case Manager Name:
Phone #:
E-mail:
Juvenile Justice Services (FREE, Probation etc.), Agency Name (if any):
Case Manager Name:
Phone #:
E-mail:
Is youth participating in a Work to Learn program?
Yes
No
If Yes, Name of Program?
Where (Location)?:
When (Days/Hours)?:
TFC Home?:
Yes
No
If Yes, please provide TFC Home Name:
Case Manager Name:
Phone #:
E-mail:
Other contact information that you feel may be helpful in coordinating services:
Additional Comments, Statements, or Anything else you would like to add or like us to know?:
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