DCYF Form 10-460 Treehouse Educational Advocacy Referral - Washington

DCYF Form 10-460 or the "Treehouse Educational Advocacy Referral" is a form issued by the Washington State Department of Children, Youth, and Families.

Download a PDF version of the DCYF Form 10-460 down below or find it on the Washington State Department of Children, Youth, and Families Forms website.

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ATTENTION: This is an electronic form in FamLink. This Word version must only be used when FamLink is not available.
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Treehouse Educational Advocacy Referral
Email to
eareferrals@dcyf.wa.gov
Student Information. All fields are required.
NAME
ALSO KNOWN AS (AKA)
DATE OF BIRTH
RACE / ETHNICITY (PLEASE SELECT ALL THAT APPLY)
African / African American
American Indian
Asian / Pacific Islander
Hispanic / Latino
GENDER
Caucasian
Multi-Racial
Male
Female
Transgender
Other (specify):
ESL / ELL FAMILY
Yes
No
Unknown
PLACEMENT
Birth Home (Information / Referral Only)
Kinship / Fictive Kin
Foster
Group Care
Other (specify):
LEGAL STATUS
Legally Free
Dependent
Guardianship
CHINS
VPA
Parental Custody
PERSONAL IDENTIFICATION NUMBER
Is the youth in a temporary placement?
Yes
No
PERMANCY PLAN
Contact Information
DCYF WORKER’S NAME
PHONE NUMBER
EMAIL ADDRESS
CAREGIVER’S NAME
PHONE NUMBER
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
Does the caregiver know this referral has been made?
Yes
No
NAME
PHONE NUMBER
Guardian Ad Litem OR
CASA:
PRIVATE PLACING AGENCY CASE MANAGER’S NAME
PHONE NUMBER
Referral Information
DATE OF EA REFERRAL
REFERRAL SOURCE
R1
R3
R5
R2
R4
R6
REFERRAL SOURCE
DCYF Office Name:
DCYF worker
CHET Screener
CURRENT ENROLLMENT STATUS
IF NOT ENROLLED OR EXPELLED, PLEASE EXPLAIN
Enrolled
Not enrolled
EDUCATIONAL PLACEMENT
SCHOOL CURRENTLY ATTENDING
General Ed
0 - 3
Special Ed (IEP)
504
GRADE IN SCHOOL
SCHOOL DISTRICT
Other:
PLEASE CHECK REFERRAL CONCERNS
Needing school services (SpEd / 504, etc.)
School discipline
School enrollment
Not progressing at grade Level (credits, retention, etc.)
Attendance
SUMMARY OF EDUCATIONAL ISSUES PROMPTING THIS REFERRAL
REFERRING CA WORKER’S SIGNATURE
DATE
* FOR ADDITIONAL QUESTIONS, PLEASE CONTACT THE TREEHOUSE EDUCATION ADVOCACY PROGRAM MANAGER AT 206.767.7000
TREEHOUSE EDUCATION ADVOCACY REFERRAL
DCYF 10-460 (02/2019) INT
ATTENTION: This is an electronic form in FamLink. This Word version must only be used when FamLink is not available.
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Treehouse Educational Advocacy Referral
Email to
eareferrals@dcyf.wa.gov
Student Information. All fields are required.
NAME
ALSO KNOWN AS (AKA)
DATE OF BIRTH
RACE / ETHNICITY (PLEASE SELECT ALL THAT APPLY)
African / African American
American Indian
Asian / Pacific Islander
Hispanic / Latino
GENDER
Caucasian
Multi-Racial
Male
Female
Transgender
Other (specify):
ESL / ELL FAMILY
Yes
No
Unknown
PLACEMENT
Birth Home (Information / Referral Only)
Kinship / Fictive Kin
Foster
Group Care
Other (specify):
LEGAL STATUS
Legally Free
Dependent
Guardianship
CHINS
VPA
Parental Custody
PERSONAL IDENTIFICATION NUMBER
Is the youth in a temporary placement?
Yes
No
PERMANCY PLAN
Contact Information
DCYF WORKER’S NAME
PHONE NUMBER
EMAIL ADDRESS
CAREGIVER’S NAME
PHONE NUMBER
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
Does the caregiver know this referral has been made?
Yes
No
NAME
PHONE NUMBER
Guardian Ad Litem OR
CASA:
PRIVATE PLACING AGENCY CASE MANAGER’S NAME
PHONE NUMBER
Referral Information
DATE OF EA REFERRAL
REFERRAL SOURCE
R1
R3
R5
R2
R4
R6
REFERRAL SOURCE
DCYF Office Name:
DCYF worker
CHET Screener
CURRENT ENROLLMENT STATUS
IF NOT ENROLLED OR EXPELLED, PLEASE EXPLAIN
Enrolled
Not enrolled
EDUCATIONAL PLACEMENT
SCHOOL CURRENTLY ATTENDING
General Ed
0 - 3
Special Ed (IEP)
504
GRADE IN SCHOOL
SCHOOL DISTRICT
Other:
PLEASE CHECK REFERRAL CONCERNS
Needing school services (SpEd / 504, etc.)
School discipline
School enrollment
Not progressing at grade Level (credits, retention, etc.)
Attendance
SUMMARY OF EDUCATIONAL ISSUES PROMPTING THIS REFERRAL
REFERRING CA WORKER’S SIGNATURE
DATE
* FOR ADDITIONAL QUESTIONS, PLEASE CONTACT THE TREEHOUSE EDUCATION ADVOCACY PROGRAM MANAGER AT 206.767.7000
TREEHOUSE EDUCATION ADVOCACY REFERRAL
DCYF 10-460 (02/2019) INT

Download DCYF Form 10-460 Treehouse Educational Advocacy Referral - Washington

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