Form CFS1452-3 "Referral Packet Documentation Checklist" - Illinois

What Is Form CFS1452-3?

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 May 1, 2013;
  • 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 CFS1452-3 by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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CFS 1452-3
5/2013
State of Illinois
Department of Children and Family Services
REFERRAL PACKET DOCUMENTATION CHECKLIST
The following checklist is a tool to be used by all stakeholders throughout the various stages in the referral process, each
time the youth is referred to a new placement/setting. Ultimately, it is the responsibility of the DCFS/POS caseworker to
ensure the documents are provided. The expectation is that every item in this document will be addressed as either
“Attached” or “Not Applicable,” in accordance with the timeframes listed below.
NOTE: SUPERVISORS HAVE THE ABILITY TO ASSIGN PARALLEL ACCESS TO SACWIS TO THE MATCHED
PROVIDERS IN ORDER FOR THEM TO ASSESS THE REFERRAL.
IF PARALLEL ACCESS IS GIVEN, ANY
DOCUMENTS THAT ARE IN SACWIS DO NOT NEED TO BE INCLUDED IN THE REFERRAL PACKET.
NAME:
ID#:
I. Centralized Matching Team Referral Documents:
These documents are sent by the Centralized Matching Team to matched providers as the initial electronic referral
packet.
Date:
Attached
N/A
CIPP, Clinical, or Residential Transition & Discharge Protocol
Initial Referral Packet Documentation Checklist (CIPP, Clinical, and Residential
1.
Transition & Discharge Protocol)
2.
CFS 1452-1 CIPP Referral (CIPP)
3.
CFS 1452-2 CIPP Action Plan (CIPP)
4.
Placement History (CIPP)
5.
Clinical Summary (Clinical, and Residential Transition & Discharge Protocol)
6.
CANS (Residential Transition & Discharge Protocol)
7.
CSR/Action Plan (Residential Transition & Discharge Protocol)
8.
Other:
Missing Documentation and Timeframe for sending document(s) once obtained:
Page 1 of 6
CFS 1452-3
5/2013
State of Illinois
Department of Children and Family Services
REFERRAL PACKET DOCUMENTATION CHECKLIST
The following checklist is a tool to be used by all stakeholders throughout the various stages in the referral process, each
time the youth is referred to a new placement/setting. Ultimately, it is the responsibility of the DCFS/POS caseworker to
ensure the documents are provided. The expectation is that every item in this document will be addressed as either
“Attached” or “Not Applicable,” in accordance with the timeframes listed below.
NOTE: SUPERVISORS HAVE THE ABILITY TO ASSIGN PARALLEL ACCESS TO SACWIS TO THE MATCHED
PROVIDERS IN ORDER FOR THEM TO ASSESS THE REFERRAL.
IF PARALLEL ACCESS IS GIVEN, ANY
DOCUMENTS THAT ARE IN SACWIS DO NOT NEED TO BE INCLUDED IN THE REFERRAL PACKET.
NAME:
ID#:
I. Centralized Matching Team Referral Documents:
These documents are sent by the Centralized Matching Team to matched providers as the initial electronic referral
packet.
Date:
Attached
N/A
CIPP, Clinical, or Residential Transition & Discharge Protocol
Initial Referral Packet Documentation Checklist (CIPP, Clinical, and Residential
1.
Transition & Discharge Protocol)
2.
CFS 1452-1 CIPP Referral (CIPP)
3.
CFS 1452-2 CIPP Action Plan (CIPP)
4.
Placement History (CIPP)
5.
Clinical Summary (Clinical, and Residential Transition & Discharge Protocol)
6.
CANS (Residential Transition & Discharge Protocol)
7.
CSR/Action Plan (Residential Transition & Discharge Protocol)
8.
Other:
Missing Documentation and Timeframe for sending document(s) once obtained:
Page 1 of 6
II Initial DCFS/POS Caseworker Referral Packet Documents:
These documents are sent by the assigned DCFS/POS caseworker to the matched providers. These documents are to
be provided immediately in order for the provider to make a disposition.
Date:
Attached
N/A
9.
Updated Referral Packet Documentation Checklist
10.
Integrated Assessment/Social History and most recent update
11.
Hispanic Client Language Determination Form CFS 1000-1
12.
Current Client Service Plan
13.
CFS 119 Unusual Incident Reports (past 90 days)
14.
Court Reports (past year minimum)
15.
Permanency Reports (past year minimum)
16.
Most Recent Treatment Plan
17.
Psychological Evaluation Report (most recent)
If IQ under 70, Measure of Adaptive Functioning (i.e., Vineland) must also be
attached
18.
Progress reports (past year minimum)
19.
Psychiatric/Mental Health Reports
a. Mental health records including Mental Health Assessments or
b. Psychiatric evaluations
c. Inpatient psychiatric hospital records
d. Other:
20.
Any other specialized assessments/plans
a. Most recent Psychosexual assessments and current level of risk
b. Substance abuse assessments and/or discharge summaries
c. Neurological Report
d. Wards Supervision Plan CFS 685
e. 0-3 Evaluation
f. Runaway Risk Assessment
g. Other:
21.
Probation Social Investigation and other Delinquency Court Evaluations
22.
Academic/Educational Records
a. Educational Behavior Management Plan
b. 504 Plan
c. Current Individualized Education Plan (IEP)
d. Current IEP Triennial Evaluation Reports
e. Education Transition Plan for special education youth 14.5 years & older
f. Other:
Page 2 of 6
Attached
N/A
23.
Ansell Casey (most recent)
a. Youth
b. Caregiver
24.
Medical documentation if specific special medical need
25.
Other:
Missing Documentation and Timeframe for sending document(s) once obtained:
III. Additional DCFS/POS Caseworker Referral Packet Documents: prior to admission:
These documents are sent by the assigned DCFS/POS caseworker. These documents are needed once a confirmed
admission has been determined.
Date:
Attached
N/A
26.
Updated Referral Packet Documentation Checklist
27.
Academic/Educational Records
a. High School Diploma
b. GED
c. Current Educational/School Transcript
d. Current Report Card
e. ISBE Student Transfer Form
f. Current CFS 407 Education Report Form
g. Current CFS 407HS Annual High School Plan
h. Other:
28.
Relapse Prevention Plan
29.
Copy of Birth Certificate
30.
Copy of Social Security Card
31.
Medical Card
Page 3 of 6
Attached
N/A
32.
Health/Medical Records
a. HealthWorks Health Passport
b. Current Physical Exam within last 12 months
c. Current TB Test
d. Current Flu Shot
e. Immunization Record
f. Dental Exam within last 12 months
g. Vision Screening
Exam (if failed)
h. Hearing Screening
Exam (if failed)
i. Other:
33.
Current Consents
a. CFS 431-B Consent for Psychotropic Medications (
for ALL prescribed psychotropic
meds)
b. CFS 415 Consent for Ordinary and Routine Medical and Dental Services
c. Consent for Behavior Treatment Techniques
d. CFS 431 Consent of Guardian to Medical/Surgical Treatment
e. Other Consents as needed
f. CFS 600-3 Signed Consent for Release of Information
g. Other:
34.
Dependency/Permanency Court Records
a. Disposition or Temporary Custody Order
b. Most recent Permanency Order
c. Updated Permanency Report
d. Other:
35.
Juvenile Delinquency Court Orders/Records
a. Police Reports and Petition for Adjudication
b. Adjudication Order
c. Sentencing/Probation Order
d. Petition to Revoke
e. Updated Probation Social Investigation
f. Other:
36.
DJJ/DOC Parole Order
Page 4 of 6
Attached
N/A
37.
Offender Registration Act—Current Registration Form
a. Juvenile Delinquent
b. Sex Offender (adult)
38.
Adult Criminal Court Orders
a. Indictment Information/Arrest Report/Criminal Complaint
b. Judgment Order (Conviction/Sentencing/Probation Order)
c. Petition to Revoke
d. Other:
39.
Child Identification Form CFS 680 (including Fingerprints and Photo of Ward)
40.
Other:
Missing Documentation and Timeframe for sending document(s) once obtained:
IV. Additional DCFS/POS Caseworker Referral Packet Documents at admission:
These items are required at the time of intake.
Date:
Attached
N/A
41.
Updated Referral Packet Documentation Checklist
42.
SSI Award letter
43.
Current contact info. of supportive individuals including related guidelines/restrictions
44.
Dates and times of next court dates
a. Delinquency
b. Permanency
45.
Date and time of next ACR
46.
Clothing-7-10 days of weather appropriate clothing
47.
CFS 534 Medication Administration Log (list including type, dosage, and times given)
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