CFS 912, Referral Form for Life Skills/Financial Literacy Education Instructions

Please provide the full street address, including the city, state, and zip code.

Provide the youth's age in years.

Enter a detailed description of any behavioral or emotional problems the youth has, including clinical diagnoses and medications, if applicable.

Provide details on when the youth is available to participate in classes, including specific days and times.

Please provide the full name of the contact person.

Please specify the relationship of the contact person.

Please provide the county of residence for the youth.

Provide the date.

Please provide the unique identification number assigned by the Department of Children and Family Services (DCFS).

Please enter the youth's date of birth.

Please provide the email address.

Provide the three-digit area code for the facsimile number.

Provide the three-digit prefix for the facsimile number.

Provide the four-digit line number for the facsimile number.

Check this box if the referral packet includes two copies of the CFS 912, Referral Form, with all requested information entered on the completed form. Fill only if 'Financial Literacy Education' is 'Yes'.

Check this box if the referral packet includes two copies of the CFS 600-3, Consent for Release of Information, signed by the youth and/or authorized agent of the Guardianship Administrator. Fill only if 'Financial Literacy Education' is 'Yes'.

Check this box if the CFS 912 Referral Form, with all requested information entered, is included in the referral packet. Fill only if 'Life Skills' is 'Yes'.

Check this box if the face sheet and the child-specific section of the current SACWIS service plan are included in the referral packet. Fill only if 'Life Skills' is 'Yes'.

Check this box if the Integrated Assessment is included in the referral packet. Fill only if 'Life Skills' is 'Yes'.

Check this box if the scored Casey Life Skills Assessment is included in the referral packet. Fill only if 'Life Skills' is 'Yes'.

Check this box if the CFS 600-3 Consent for Release of Information, signed by the youth and/or authorized agent of the Guardianship Administrator, is included in the referral packet. Fill only if 'Life Skills' is 'Yes'.

Provide the full name of the DCFS/POS worker.

Check this box if the youth has a physical disability.

Check this box if the youth does not have a physical disability.

Enter the specific type of physical disability the youth has. Fill only if 'Yes' is 'Yes'.

Check this box if the referral is for a youth in foster care, aged 14 to 21 years, for Life Skills.

Check this box if the referral is for a youth in DCFS managed placement, within 30 days of attaining 19 years of age, for Financial Literacy Education.

Provide a detailed description of any safety-related concerns.

Please enter the full name of the supervisor.

Please enter the first part of the supervisor's telephone number.

Please enter the second part of the supervisor's telephone number.

Please enter the third part of the supervisor's telephone number.

Enter the three-digit area code for the home telephone number.

Enter the first three digits of the home telephone number.

Enter the last four digits of the home telephone number.

Enter the three-digit area code for the work or message telephone number.

Enter the first three digits of the work or message telephone number.

Enter the last four digits of the work or message telephone number.

Provide details regarding any transportation issues for the youth and explain how they will get to classes.

Please provide the complete street address, city, state, and zip code for the worker.

Please provide the name of the worker's agency.

Please provide the worker's complete email address.

Provide the Worker's R/S/F identifier for the caseworker.

Please provide the three-digit area code for the worker's telephone number.

Please provide the three-digit prefix for the worker's telephone number.

Please provide the four-digit line number for the worker's telephone number.

Please enter the complete street address, including city, state, and zip code, for the youth.

Enter the area code of the youth's cell phone number.

Enter the three-digit prefix of the youth's cell phone number.

Enter the four-digit line number of the youth's cell phone number.

Please provide the email address for the youth.

Check this box if the youth's learning style is auditory, meaning they learn best by hearing information.

Check this box if the youth's learning style is visual, meaning they learn best by seeing information or demonstrations.

Check this box if the youth's learning style is participatory, meaning they learn best through active engagement and hands-on activities.

Please provide the full name of the youth.

Enter the three-digit area code for the youth's telephone number.

Enter the three-digit prefix for the youth's telephone number.

Enter the four-digit line number for the youth's telephone number.