Form CFS468-1 "Adoption Listing Service (Als) Child Registration Form" - Illinois

What Is Form CFS468-1?

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 June 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 CFS468-1 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 CFS468-1 "Adoption Listing Service (Als) Child Registration Form" - Illinois

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Adoption Information Center of IL
FOR AICI USE ONLY:
PH
Adoption Listing Service (ALS)
Listing Number:
EP
Child Registration Form
Age Category:
MR
DCFS Region:
LD
INSTRUCTIONS: Complete a separate form for each child, including
Adoption Listing Worker:
DD
each child in a sibling group. IF TPR HAS OCCURRED, include one
Change Notice Date:
SA
professional, color photo; do not tape, paper clip or staple photograph to
the form.
Juvenile Court
DE
Photo taken:
HIV
On bottom of back of photo, attach a label with the following:
1. Full name of child
CO
2. Name of agency & worker
3. Date picture was taken
CHILD’S LEGAL STATUS:
4. If sibling group picture, identify each child
Date TPR occurred:
Or, if no TPR
Photographer Name:
Date passed adoption screening:
Location photo was taken:
Or, if not passed screening
Photographer Phone Number:
Date passed pre-screening:
Complete four sides of this form and mail form, CFS 600-3* & photo to:
Termination under appeal:
AICI, 120 W. Madison Street, Suite 800, Chicago 60602
Guardianship date:
If questions, call 312/346-1516
Other (explain)
CONSENT FOR ALS LISTING
CHILD’S FULL NAME:
Court Docket #
Name:
DCFS GUARDIAN’S SIGNATURE
Birth date:
DCFS ID#:
Race/Ethnicity:
Gender:
Male
Female
nt
By DCFS Authorized Age
Is this child being listed as part of a sibling group?
Yes
No
DATE:
(Signature above grants consent for ALS registration only and
Use CFS 600-3, Consent for Release of Information form for children ages 12 and up,
use of child’s photo if TPR has occurred.)
to consent to their mental health information appearing in the ALS Matching Book.
REGION/SITE/FIELD NUMBER:
CONSENT FOR RECRUITMENT USING
PRIVATE AGENCY
CHILD’S PHOTO, IF TPR HAS OCCURRED:
Potential Recruitment Opportunities:
Child’s Worker:
Newspaper Waiting Child Series
TV Waiting Child Series
Supervisor:
Adoptive or Foster Parent Newsletters
Agency:
National Photolisting Book (CAP)
Photolisting Web Sites
Address:
National Adoption Exchanges
City:
Zip:
Please specify if there are any Recruitment opportunities
Phone:
(
)
Fax:
(
)
listed above in which child cannot be featured:
E-mail:
Cities/Counties in which child cannot be featured:
DCFS OFFICE
Region/Site/Field:
If child’s real name should not be used, specify name to use in
Worker/Liaison:
recruitment:
Supervisor:
DCFS GUARDIAN SIGNATURE
Address:
City:
Zip:
By DCFS Authorized Agency
Phone:
(
)
Fax:
(
)
DATE:
E-mail:
(Signature above grants consent for all recruitment)
CFS 468-1
ALS-1
6/2007
3/2002
Adoption Information Center of IL
FOR AICI USE ONLY:
PH
Adoption Listing Service (ALS)
Listing Number:
EP
Child Registration Form
Age Category:
MR
DCFS Region:
LD
INSTRUCTIONS: Complete a separate form for each child, including
Adoption Listing Worker:
DD
each child in a sibling group. IF TPR HAS OCCURRED, include one
Change Notice Date:
SA
professional, color photo; do not tape, paper clip or staple photograph to
the form.
Juvenile Court
DE
Photo taken:
HIV
On bottom of back of photo, attach a label with the following:
1. Full name of child
CO
2. Name of agency & worker
3. Date picture was taken
CHILD’S LEGAL STATUS:
4. If sibling group picture, identify each child
Date TPR occurred:
Or, if no TPR
Photographer Name:
Date passed adoption screening:
Location photo was taken:
Or, if not passed screening
Photographer Phone Number:
Date passed pre-screening:
Complete four sides of this form and mail form, CFS 600-3* & photo to:
Termination under appeal:
AICI, 120 W. Madison Street, Suite 800, Chicago 60602
Guardianship date:
If questions, call 312/346-1516
Other (explain)
CONSENT FOR ALS LISTING
CHILD’S FULL NAME:
Court Docket #
Name:
DCFS GUARDIAN’S SIGNATURE
Birth date:
DCFS ID#:
Race/Ethnicity:
Gender:
Male
Female
nt
By DCFS Authorized Age
Is this child being listed as part of a sibling group?
Yes
No
DATE:
(Signature above grants consent for ALS registration only and
Use CFS 600-3, Consent for Release of Information form for children ages 12 and up,
use of child’s photo if TPR has occurred.)
to consent to their mental health information appearing in the ALS Matching Book.
REGION/SITE/FIELD NUMBER:
CONSENT FOR RECRUITMENT USING
PRIVATE AGENCY
CHILD’S PHOTO, IF TPR HAS OCCURRED:
Potential Recruitment Opportunities:
Child’s Worker:
Newspaper Waiting Child Series
TV Waiting Child Series
Supervisor:
Adoptive or Foster Parent Newsletters
Agency:
National Photolisting Book (CAP)
Photolisting Web Sites
Address:
National Adoption Exchanges
City:
Zip:
Please specify if there are any Recruitment opportunities
Phone:
(
)
Fax:
(
)
listed above in which child cannot be featured:
E-mail:
Cities/Counties in which child cannot be featured:
DCFS OFFICE
Region/Site/Field:
If child’s real name should not be used, specify name to use in
Worker/Liaison:
recruitment:
Supervisor:
DCFS GUARDIAN SIGNATURE
Address:
City:
Zip:
By DCFS Authorized Agency
Phone:
(
)
Fax:
(
)
DATE:
E-mail:
(Signature above grants consent for all recruitment)
CFS 468-1
ALS-1
6/2007
3/2002
ADOPTION ASSISTANCE:
(Check all that apply)
Monthly
Conditional
Medical
Other
Placement History & Plans:
Date child entered substitute care:
Total number of placements:
Date entered current placement:
Religious preference:
Language(s) spoken by child:
Primary language:
Does the foster parent or a relative want to adopt this child?
Yes
No
Is this child available for adoptive placement with a new family?
Yes
No
CURRENT FOSTER PARENT INFOMRATION:
Name:
Phone:
Address:
(Street)
(City)
(State & Zip)
County:
SIBLING INFORMATION (Use additional paper, if needed):
Names of siblings with whom child has ongoing visits:
Names of siblings whose goal/plan is adoption:
(Indicate by each child’s name whether siblings must (m), should (s), should not (n), or cannot (c) be adopted with this child)
Names of siblings who are to be listed with this child:
Are any of these siblings twins
or triplets
? (Check)
Names of twins/triplets:
Would you consider an adoptive family that is only able to adopt part of this sibling group?
Yes
No
If yes, which siblings should be adopted together?
If no, why not? (Explain)
PROFILE FOR PRESPECTIVE ADOPTIVE FAMILIES BASED ON THE BEST INTERESTS OF THE CHILD:
PARENTAL PROFILE: (Check all that apply)
CHILDREN IN ADOPTIVE HOME: (Check one only)
Two-parent family
Any age
Single parent
Younger
Urban family
Older
Rural family
None
IL or out-of-state family
Family of specific geographic preferred*
Explain
* Specify geographic area preferred; document how this is going to meet child’s best interest. (NOTE: Section 202 of Adoption and Safe Families
Act of 1997 requires states to develop plans to use cross-jurisdictional resources to effect timely adoptive placements for waiting children.)
WHAT SKILLS AND EXPERIENCE SHOULD THE FAMILY ADOPTING THIS CHILD HAVE?
CFS 468-1
ALS-1
6/2007
3/2002
EDUCATION
Child’s present grade:
If child functioning at the appropriate grade/developmental level?
Yes
No
Check all that apply and indicate whether their attendance is Full Time (FT) or Part Time (PT):
Classroom type:
Special Ed services required:
Setting:
Regular
Physical therapy
Public school
Learning Disabled
Occupational therapy
Parochial
Behavior Disorder
Speech/language therapy
Other private
Ungraded
Sign Language
Residential
Developmental
Early childhood 0-3 y
Preschool/Headstart
Other (specify)
Pre-kindergarten
Indicate below any DIAGNOSED disabilities/conditions of this child by circling the number indicating severity:
1 = mild
2 = moderate
3 = severe
LEARNING DISABILITY
None
1
Mild
Needs Resource Room help in school setting
2
Moderate
Requires several years of special education to learn to compensate
3
Severe
Requires long-term special education; will always have difficulty with one or more learning areas
MENTAL RETARDATION
None
1
Mild
IQ = 50-75
Can achieve employment on an unskilled or semi-skilled level with minimum support; may be able to participate in
the mainstream of community life with a job & independent living
2
Moderate
IQ = 25-50
May work in an unskilled or semi-skilled capacity in a sheltered environment; must live in a group home or family
situation where supervision is available
3
Severe
IQ = less
Must work or attend day care in a totally supervised setting; individual has some motor and speech problems; may
than 25
need nursing care; limited self-care ability.
PHYSICAL/MEDICAL CONDITIONS
None
1
2
3
Asthma
1
2
3
Hearing Impaired
1
2
3
Autism
1
2
3
Hydrocephalus
1
2
3
Cerebral Palsy
1
2
3
Muscular Dystrophy
1
2
3
Developmental Delay
1
2
3
Seizures
1
2
3
Down Syndrome
1
2
3
Sickle Cell Anemia
1
2
3
Fetal Alcohol Effect
1
2
3
Sickle Cell Trait
1
2
3
Fetal Alcohol Syndrome
1
2
3
Spina Bifida
1
2
3
Genetic Medical Conditions (Specify)
1
2
3
Visually Impaired
1
2
3
Other (Specify)
Is this child Developmentally Disabled according to the following Federal definition:
Yes
No
DEVELOPMENTAL DISABILITY: A severe, chronic disability which is attributable to a mental and/or physical impairment; is manifested before
the age of twenty-two; is likely to continue indefinitely; results in the substantial functional limitations in three or more of the following major life
activities; 1) self-care; 2) receptive and expressive language; 3) learning; 4) mobility; 5) self-direction; 6) capacity for independent living; and 7)
economic self-sufficiency; and reflects the person's need for a combination of special care, treatment, or other services which are lifelong or of
extended duration.
EMOTIONAL/BEHAVIORAL CONDITIONS
None
1
2
3
Adjustment Disorder
1
2
3
Eating Disorder
1
2
3
Attachment Disorder
1
2
3
Enuresis
1
2
3
Behavior Disorder
1
2
3
Post Traumatic Stress Disorder
1
2
3
Childhood Anti-Social Behavior
1
2
3
Oppositional Defiant Disorder
1
2
3
Attention Deficit Disorder
1
2
3
Sexually Acts Out
1
2
3
Attention Deficit Hyperactivity Disorder
1
2
3
Other (Specify)
1
2
3
Compulsive Disorder
Please answer the following:
I have verified that the information on this page is
Prenatal Drug Exposure
Yes
No
accurate, diagnosed and documented in the child’s
HIV Positive*
Yes
No
record and that all information on pages one and two
Diagnosed with AIDS*
Yes
No
is accurate.
Child attends counseling
Yes
No
*Condition shall be disclosed in accordance with DCFS Rule 431,
Supervisor’s Signature
Date
Confidentiality of Personal Information, subsection 431.100(b)(4).
CFS 468-1
ALS-1
6/2007
3/2002
Provide a detailed description of the child including the following information (use an additional sheet, if necessary):
Personality including strengths, weaknesses & special talents:
Favorite toys/activities/hobbies/pets:
Behavior at home & school:
Overall health and medication taken, if applicable:
State positive comments the foster parent & teachers make about child:
Ability to attach and express-receive affection, counseling needs and readiness for placement: (Include need for any on-going visiting with birth family
members or others.)
Ask the child what he/she would like their adoptive family to be life: (Include a quote from child, if possible.)
CFS 468-1
ALS-1
6/2007
3/2002
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