Form CFS685 "Ward's Supervision Plan" - Illinois

What Is Form CFS685?

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 January 1, 2007;
  • 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 CFS685 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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Download Form CFS685 "Ward's Supervision Plan" - Illinois

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CFS 685
S
tate of Illinois
Rev. 1/2007
Department of Children and Family Services
WARD’S SUPERVISION PLAN
Filing Instructions: Upon completion, the CFS 685 Ward’s Supervision Plan is to be filed in Section
VI Child Specific Section of the case record.
Date of Plan
WARD’S INFORMATION
Name of Ward
Date of Birth
Male
Female
Ward’s ID#
R/S/F
Ward’s Primary Language
CASEWORKER INFORMATION
Name
Agency
Phone
FAX
Supervisor’s Name
R/S/F
Please check the behavior or condition that may create a risk for this ward or for others:
Physical Aggression
Delinquent Behaviors
Runaway
Risk of Harm to Self
Suicidal Ideation
Homicidal Threats
Fire Setting
Psychiatric Condition
Alcohol or Substance Misuse
Level of Functioning/ Cognitive Problem
Psychotropic Medication Use or Refusal
Medical Condition
Medication refusal
Gang Involvement
Risk of Sexual Victimization
Sexually Active
Other: Describe
Sexual Behavior Problem
***Note:
Supervision Plan is not valid without the signature of the Sexual
Abuse Services Coordinator when this box is checked.
Is the ward pending legal charges for a sex offense?
yes
no
Is the ward adjudicated/convicted of a sex offense?
yes
no
Is sex offender registration required?
yes
no
If yes, a copy of the registration must be attached to this Plan.
What is the risk to others?
to other children
to adults
to property
Please detail:
What treatment and/or services are currently being provided to address these risks?
Please detail:
- 1 -
CFS 685
S
tate of Illinois
Rev. 1/2007
Department of Children and Family Services
WARD’S SUPERVISION PLAN
Filing Instructions: Upon completion, the CFS 685 Ward’s Supervision Plan is to be filed in Section
VI Child Specific Section of the case record.
Date of Plan
WARD’S INFORMATION
Name of Ward
Date of Birth
Male
Female
Ward’s ID#
R/S/F
Ward’s Primary Language
CASEWORKER INFORMATION
Name
Agency
Phone
FAX
Supervisor’s Name
R/S/F
Please check the behavior or condition that may create a risk for this ward or for others:
Physical Aggression
Delinquent Behaviors
Runaway
Risk of Harm to Self
Suicidal Ideation
Homicidal Threats
Fire Setting
Psychiatric Condition
Alcohol or Substance Misuse
Level of Functioning/ Cognitive Problem
Psychotropic Medication Use or Refusal
Medical Condition
Medication refusal
Gang Involvement
Risk of Sexual Victimization
Sexually Active
Other: Describe
Sexual Behavior Problem
***Note:
Supervision Plan is not valid without the signature of the Sexual
Abuse Services Coordinator when this box is checked.
Is the ward pending legal charges for a sex offense?
yes
no
Is the ward adjudicated/convicted of a sex offense?
yes
no
Is sex offender registration required?
yes
no
If yes, a copy of the registration must be attached to this Plan.
What is the risk to others?
to other children
to adults
to property
Please detail:
What treatment and/or services are currently being provided to address these risks?
Please detail:
- 1 -
Ward’s Name
PLACEMENT INFORMATION
Caregiver
Phone
Address
Placement Date
Type of Placement:
Foster Home
Specialized Foster Home
Institution
Group Home
Foster Home Adoptive
ERC/Shelter
TLP
ILO
Other
List the names, ages, and sex of other wards and children in the home. If the child is not a ward, write the child’s
initials instead of his or her name.
Ward/Child’s Name/Initials
Sex
Age
Ward
Ward/Child’s Name/Initials
Sex
Age
Ward
Ward/Child’s Name/Initials
Sex
Age
Ward
Ward/Child’s Name/Initials
Sex
Age
Ward
Ward/Child’s Name/Initials
Sex
Age
Ward
Are any of the children in the home especially vulnerable because of one of the following factors?
Physically handicapped
Developmental disability
History of sexual victimization
Younger and/or smaller
History of Sexually Problematic or
Other
Aggressive Behavior
Check here if caseworkers of all other children in the home have been informed of this ward’s risk behaviors.
TREATMENT PROVIDER INFORMATION
Name
Agency
Phone
FAX
Treatment Type:
Outpatient
Residential/Group Home
Is this provider a certified SBP provider?
Yes
No
- 2 -
Ward’s Name
SUPERVISION
Describe in detail how an effective level of supervision will be provided to the ward during the following routine
activities within the home:
Bedtime/Sleeping:
Bathing/Dressing:
Playtime/Leisure:
List any activities that have been disallowed, such as overnights with others, being unsupervised with younger
children, etc.
1.
2.
3.
4.
Describe recreational activities and opportunities to socialize with peers that will be provided to this ward:
1.
How often?
2.
How often?
3.
How often?
4.
How often?
5.
How often?
- 3 -
Ward’s Name
Are there other specific situations in the school where behavioral or safety concerns warrant notification
and involvement with Supervision Planning in specific areas?
Yes
No
If yes, attach the DCFS Ward’s Supervision Plan – Educational Addendum and the
consent for Release of Information.
***Note: Supervision Planning in the school for wards with sexual behavior problems must have prior
approval by the Sexual Abuse Services Coordinator.
Are there other specific situations in the community where behavioral or safety concerns warrant
notification and involvement with Supervision Planning in specific areas?
Yes
No
If yes, attach the DCFS Ward’s Supervision Plan – Community Addendum and the
consent for Release of Information.
***Note: Supervision Planning in the community for wards with sexual behavior problems must have
prior approval by the Sexual Abuse Services Coordinator.
Signatures
I am responsible for the Supervision Plan for this ward. I have been informed of the reasons this ward requires
special supervision. I agree to provide or arrange for this supervision as needed:
Signature of Caregiver or Provider
Date
Other
Relationship
Date
Other
Relationship
Date
Other
Relationship
Date
Other
Relationship
Date
Other
Relationship
Date
Signature of Ward, if age 12 or older
Date
Ward refused to sign Supervision Plan, but is aware of its existence.
This is the Supervision Plan that is in place for this ward. I have reviewed this information with the above persons.
Caseworker
Date
Supervisor
Date
Other
Relationship
Date
Other
Relationship
Date
Other
Relationship
Date
Sexual Abuse Services Coordinator
Date
- 4 -
PLACEMENT CLEARANCE REQUIREMENTS
(For use only by the Sexual Abuse Services Coordinator)
Name of Ward:
I.D.:
D.O.B.
/
/
Male
Female
Referred for Placement at:
Provider:
I.D.:
I.
This child should be the only child in this home (includes biological children of caretaker, siblings,
or other wards of DCFS).
STOP: If this item is checked, it is not necessary to complete Sections II and III.
II.
This ward may be placed with other children who are:
or older.
Females who are
or older.
Males who are
or older.
III.
This ward may not be placed with other children:
No additional children should be placed in the home being considered.
Who are physically handicapped or mentally retarded.
Who are identified as children with sexual behavior problems.
Who are victims of sexual abuse.
/
/
Sexual Abuse Services Coordinator
Effective Date
NOTE: PLEASE BE ADVISED THAT THE CRITERIA NOTED ABOVE MUST BE FOLLOWED
FOR PLACEMENT OF THIS WARD IN RESPITE CARE.
-------------------------------------------------------------------------------------------------------------------------------
PCD was advised to remove the “HOLD” on this home effective
/
/
Date
REASON:
Signature:
Sexual Abuse Services Coordinator
- 5 -
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