DCFS Help Unit Consultation Request Form Instructions
This form contains 121 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Case Information | ||
| Case Name | Text |
Please enter the full name of the case.
|
| DCFS ID Number | Text |
Please enter the identification number assigned by DCFS.
|
| Agency Name | Text |
Please enter the name of the agency, if applicable. Fill only if 'POS' is 'Yes'.
Depends on:
POS
|
| Concerns Description | ||
| Description of Concerns | Text |
Provide a detailed description of the concerns checked and any additional concerns identified. Fill only if 'First Foster Child Domestic Violence Issues', 'First Foster Child Sexual Abuse Issues', 'First Foster Child Educational Issues', 'Second Foster Child Domestic Violence Concerns', 'Second Foster Child Sexual Abuse Concerns', 'Second Foster Child Educational Issues' is 'Yes' for any.
Depends on:
First Foster Child Domestic Violence Issues, First Foster Child Sexual Abuse Issues, First Foster Child Educational Issues, Second Foster Child Domestic Violence Concerns, Second Foster Child Sexual Abuse Concerns, Second Foster Child Educational Issues
|
| DCFS Involvement | ||
| Current and Previous DCFS Involvement | Text |
Provide details regarding any current or previous involvement with the Department of Children and Family Services.
|
| Fifth Concern Row | ||
| Fifth Row Substance Abuse Issues | Text |
Provide details regarding substance abuse issues for the foster child in this row.
|
| Fifth Row Physical/Mental Health Issues | Text |
Provide details regarding physical or mental health issues for the foster child in this row.
|
| Fifth Row Domestic Violence Issues | Text |
Provide details regarding domestic violence issues for the foster child in this row.
|
| Fifth Row Sexual Abuse Issues | Text |
Provide details regarding sexual abuse issues for the foster child in this row. Fill only if 'Fifth Row Substance Abuse Issues', 'Fifth Row Physical/Mental Health Issues', 'Fifth Row Domestic Violence Issues' is checked, for any.
Depends on:
Fifth Row Substance Abuse Issues, Fifth Row Physical/Mental Health Issues, Fifth Row Domestic Violence Issues
|
| Fifth Household Member | ||
| Name | Text |
Enter the full name of the household member.
|
| Relationship | Text |
Enter the household member's relationship to the primary individual or head of household.
|
| Date of Birth | Date |
Enter the household member's date of birth.
|
| Substance Abuse Issues | Text |
Provide details regarding any substance abuse issues the household member may have.
|
| Physical or Mental Health Issues | Text |
Provide details regarding any physical or mental health issues the household member may have.
|
| Domestic Violence Issues | Text |
Provide details regarding any issues with domestic violence the household member may have experienced or been involved in.
|
| Sexual Abuse Issues | Text |
Provide details regarding any issues with sexual abuse the household member may have experienced or been involved in.
|
| Educational Issues | Text |
Provide details regarding any educational issues the household member may have.
|
| First Concern Row | ||
| Relationship | Text |
Please provide the relationship of the individual to the foster parent(s).
|
| Date of Birth | Date |
Please provide the individual's date of birth.
|
| Substance Abuse Issues | Text |
Please describe any issues related to substance abuse for this individual.
|
| Physical or Mental Health Issues | Text |
Please describe any issues related to physical or mental health for this individual.
|
| First Foster Child Concerns | ||
| First Foster Child Domestic Violence Issues | Text |
Provide details regarding any issues with domestic violence that the first foster child may have experienced or been involved with.
|
| First Foster Child Sexual Abuse Issues | Text |
Provide details regarding any issues with sexual abuse that the first foster child may have experienced or been involved with.
|
| First Foster Child Educational Issues | Text |
Provide details regarding any educational issues that the first foster child may have.
|
| First Household Member | ||
| Name | Text |
Enter the full name of the first household member.
|
| Relationship | Text |
Enter the relationship of this household member to the head of the household or the primary individual.
|
| Date of Birth | Date |
Enter the date of birth for this household member.
|
| Substance Abuse Issues | Text |
Provide details regarding any issues with substance abuse for this household member.
|
| Physical or Mental Health Issues | Text |
Provide details regarding any physical or mental health issues for this household member.
|
| Domestic Violence Issues | Text |
Provide details regarding any issues with domestic violence for this household member.
|
| Sexual Abuse Issues | Text |
Provide details regarding any issues with sexual abuse for this household member.
|
| Educational Issues | Text |
Provide details regarding any educational issues for this household member.
|
| Fourth Concern Row | ||
| Fourth Row Substance Abuse Concerns | Text |
Enter any identified concerns related to substance abuse for the foster child in this row.
|
| Fourth Row Physical or Mental Health Concerns | Text |
Enter any identified concerns related to physical or mental health for the foster child in this row.
|
| Fourth Row Domestic Violence Concerns | Text |
Enter any identified concerns related to domestic violence for the foster child in this row.
|
| Fourth Row Sexual Abuse Concerns | Text |
Enter any identified concerns related to sexual abuse for the foster child in this row. Fill only if 'Fourth Row Substance Abuse Concerns', 'Fourth Row Physical or Mental Health Concerns', 'Fourth Row Domestic Violence Concerns' is checked, for any.
Depends on:
Fourth Row Substance Abuse Concerns, Fourth Row Physical or Mental Health Concerns, Fourth Row Domestic Violence Concerns
|
| Fourth Foster Child Concerns | ||
| Fourth Child Domestic Violence Concerns | Text |
Provide details regarding any domestic violence issues for the fourth foster child.
|
| Fourth Child Sexual Abuse Concerns | Text |
Provide details regarding any sexual abuse issues for the fourth foster child.
|
| Fourth Child Educational Concerns | Text |
Provide details regarding any educational issues for the fourth foster child.
|
| Fourth Household Member | ||
| Fourth Household Member Name | Text |
Enter the full name of the fourth household member.
|
| Fourth Household Member Relationship | Text |
Enter the relationship of the fourth household member to the primary individual.
|
| Fourth Household Member Date of Birth | Date |
Enter the date of birth for the fourth household member.
|
| Fourth Household Member Substance Abuse Issues | Text |
Indicate any issues related to substance abuse for the fourth household member.
|
| Fourth Household Member Physical or Mental Health Issues | Text |
Indicate any issues related to physical or mental health for the fourth household member.
|
| Fourth Household Member Domestic Violence Issues | Text |
Indicate any issues related to domestic violence for the fourth household member.
|
| Fourth Household Member Sexual Abuse Issues | Text |
Indicate any issues related to sexual abuse for the fourth household member.
|
| Fourth Household Member Educational Issues | Text |
Indicate any educational issues for the fourth household member.
|
| General | ||
| DCFS | Checkbox |
Check this box if the involvement is directly with DCFS (Department of Children and Family Services).
|
| POS | Checkbox |
Check this box if the involvement is with a POS (Purchase of Service) agency.
|
| Text6 | Text | |
| Text7 | Text | |
| Text8 | Text | |
| Text9 | Text | |
| Text10 | Text | |
| Text51 | Text | |
| Text52 | Text | |
| Text53 | Text | |
| Text54 | Text | |
| Text55 | Text | |
| Text56 | Text | |
| Text64 | Text | |
| Text72 | Text | |
| Text80 | Text | |
| Foster Child 1 Domestic Violence Issues | Text |
Provide details regarding domestic violence issues for the first foster child listed.
|
| Foster Child 1 Sexual Abuse Issues | Text |
Provide details regarding sexual abuse issues for the first foster child listed.
|
| Foster Child 1 Educational Issues | Text |
Provide details regarding educational issues for the first foster child listed.
|
| Text88 | Text | |
| Text96 | Text | |
| Text88 | Text | |
| Foster Child 2 Domestic Violence Issues | Text |
Provide details regarding domestic violence issues for the second foster child listed.
|
| Foster Child 2 Sexual Abuse Issues | Text |
Provide details regarding sexual abuse issues for the second foster child listed.
|
| Foster Child 2 Educational Issues | Text |
Provide details regarding educational issues for the second foster child listed.
|
| Text96 | Text | |
| Additional Concerns Description | Text |
Describe the concerns checked in the table above and list any additional identified concerns.
|
| Text97 | Text | |
| Text98 | Text | |
| Text99 | Text | |
| Text100 | Text | |
| Text101 | Text | |
| Text102 | Text | |
| Text103 | Text | |
| Text104 | Text | |
| Text105 | Text | |
| Text106 | Text | |
| Page 3 | ||
| Additional Information | Text |
Provide any additional information relevant to this case for discussion in the Help Unit, and attach supporting documentation. Fill only if any concern is checked in the BIOLOGICAL HOUSEHOLD COMPOSITION table.
Depends on:
Substance Abuse Issues, Physical or Mental Health Issues, Domestic Violence Issues, Sexual Abuse Issues, Educational Issues, Second Household Member Substance Abuse Issues, Second Household Member Physical or Mental Health Issues, Second Household Member Domestic Violence Issues, Second Household Member Sexual Abuse Issues, Second Household Member Educational Issues, Third Household Member Substance Abuse Issues, Third Household Member Physical or Mental Health Issues, Third Household Member Domestic Violence Issues, Third Household Member Sexual Abuse Issues, Third Household Member Educational Issues, Fourth Household Member Substance Abuse Issues, Fourth Household Member Physical or Mental Health Issues, Fourth Household Member Domestic Violence Issues, Fourth Household Member Sexual Abuse Issues, Fourth Household Member Educational Issues, Substance Abuse Issues, Physical or Mental Health Issues, Domestic Violence Issues, Sexual Abuse Issues, Educational Issues
|
| Signature Date | Date |
Enter the date the form was signed by the caseworker.
|
| Date Received | Date |
Enter the date the information was received.
|
| Second Concern Row | ||
| Relationship | Text |
Enter the relationship of this foster child to the head of household or other family members.
|
| Date of Birth | Date |
Provide the date of birth for this foster child.
|
| Substance Abuse Issues | Text |
Describe any issues with substance abuse for this foster child.
|
| Physical or Mental Health Issues | Text |
Describe any physical or mental health issues for this foster child.
|
| Second Foster Child Concerns | ||
| Second Foster Child Domestic Violence Concerns | Text |
Indicate any issues with domestic violence related to the second foster child.
|
| Second Foster Child Sexual Abuse Concerns | Text |
Indicate any issues with sexual abuse related to the second foster child.
|
| Second Foster Child Educational Issues | Text |
Indicate any educational issues related to the second foster child.
|
| Second Household Member | ||
| Second Household Member Name | Text |
Provide the full name of the second household member.
|
| Second Household Member Relationship | Text |
Enter the relationship of the second household member to the primary individual or household head.
|
| Second Household Member Date of Birth | Date |
Enter the date of birth for the second household member.
|
| Second Household Member Substance Abuse Issues | Text |
Describe any issues related to substance abuse concerning the second household member.
|
| Second Household Member Physical or Mental Health Issues | Text |
Describe any physical or mental health issues concerning the second household member.
|
| Second Household Member Domestic Violence Issues | Text |
Describe any issues related to domestic violence concerning the second household member.
|
| Second Household Member Sexual Abuse Issues | Text |
Describe any issues related to sexual abuse concerning the second household member.
|
| Second Household Member Educational Issues | Text |
Describe any educational issues concerning the second household member.
|
| Sixth Concern Row | ||
| Substance Abuse Concern | Text |
Enter details if there are concerns regarding substance abuse for the foster child in this row.
|
| Physical or Mental Health Concern | Text |
Enter details if there are concerns regarding physical or mental health for the foster child in this row.
|
| Domestic Violence Concern | Text |
Enter details if there are concerns regarding domestic violence for the foster child in this row.
|
| Sexual Abuse Concern | Text |
Enter details if there are concerns regarding sexual abuse for the foster child in this row.
|
| Third Concern Row | ||
| Third Child D.O.B. | Date |
Enter the date of birth for the third foster child listed in the composition.
|
| Third Child Substance Abuse Issues | Text |
Describe any substance abuse issues for the third foster child.
|
| Third Child Physical or Mental Health Issues | Text |
Describe any physical or mental health issues for the third foster child.
|
| Third Child Domestic Violence Issues | Text |
Describe any domestic violence issues for the third foster child. Fill only if 'Third Child D.O.B.', 'Third Child Substance Abuse Issues', 'Third Child Physical or Mental Health Issues' is checked, for any.
Depends on:
Third Child D.O.B., Third Child Substance Abuse Issues, Third Child Physical or Mental Health Issues
|
| Third Foster Child Concerns | ||
| Third Foster Child Domestic Violence Concerns | Text |
Provide details regarding any domestic violence issues for the third foster child.
|
| Third Foster Child Sexual Abuse Concerns | Text |
Provide details regarding any sexual abuse issues for the third foster child.
|
| Third Foster Child Educational Concerns | Text |
Provide details regarding any educational issues for the third foster child.
|
| Third Household Member | ||
| Third Household Member Name | Text |
Enter the full name of the third household member.
|
| Third Household Member Relationship | Text |
Enter the relationship of the third household member to the primary case individual.
|
| Third Household Member Date of Birth | Date |
Enter the date of birth for the third household member.
|
| Third Household Member Substance Abuse Issues | Text |
Indicate if the third household member has issues with substance abuse.
|
| Third Household Member Physical or Mental Health Issues | Text |
Indicate if the third household member has physical or mental health issues.
|
| Third Household Member Domestic Violence Issues | Text |
Indicate if the third household member has issues with domestic violence.
|
| Third Household Member Sexual Abuse Issues | Text |
Indicate if the third household member has issues with sexual abuse.
|
| Third Household Member Educational Issues | Text |
Indicate if the third household member has educational issues.
|