Intensive Placement Stabilization (IPS) Referral Form Instructions
This form contains 120 fields organized into 26 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Collateral Information Request | ||
| Additional Collateral Information | Checkbox |
Check this box if you are requesting additional collateral information.
|
| Additional Collateral Information Type | Text |
Provide the specific type of additional collateral information being requested. Fill only if 'Additional Collateral Information' is 'Yes'.
Depends on:
Additional Collateral Information
|
| Caseworker Information | ||
| Caseworker Agency | Text |
Provide the name of the caseworker's agency.
|
| Caseworker Name | Text |
Provide the full name of the caseworker.
|
| Caseworker Agency Address | Text |
Provide the full address of the caseworker's agency.
|
| Caseworker Phone | Text |
Provide the primary phone number for the caseworker.
|
| Caseworker Fax | Text |
Provide the fax number for the caseworker.
|
| Child Information | ||
| Child's Name | Text |
Enter the full legal name of the child.
|
| Child ID | Text |
Enter the unique identification number assigned to the child.
|
| Date of Birth | Date |
Enter the child's date of birth.
|
| Gender | Text |
Enter the child's gender.
|
| Child's Primary Language | Text |
Enter the child's primary spoken language.
|
| DCFS Case Opening Date | Date |
Enter the date the DCFS case for the child was opened.
|
| Counseling Reports Request | ||
| Counseling Reports | Checkbox |
Check this box if you are requesting counseling reports.
|
| Counseling Reports Type | Text |
Enter the specific type of counseling reports being requested. Fill only if 'Counseling Reports' is 'Yes'.
Depends on:
Counseling Reports
|
| Current Setting | ||
| POS Traditional/HMR Foster Home | Checkbox |
Check this box if the child's current setting is a POS Traditional/HMR Foster Home.
|
| POS Specialized Foster Home | Checkbox |
Check this box if the child's current setting is a POS Specialized Foster Home.
|
| DCFS Foster Home | Checkbox |
Check this box if the child's current setting is a DCFS Foster Home.
|
| Home of Parent | Checkbox |
Check this box if the child's current setting is the Home of Parent.
|
| Emergency Shelter | Checkbox |
Check this box if the child's current setting is an Emergency Shelter.
|
| Institution/Group Home | Checkbox |
Check this box if the child's current setting is an Institution or Group Home.
|
| Hospitalization due to medical condition | Checkbox |
Check this box if the child's current setting is hospitalization due to a medical condition.
|
| Psychiatric Hospitalization | Checkbox |
Check this box if the child's current setting is psychiatric hospitalization.
|
| Other, Specify Setting | Checkbox |
Check this box if the child's current setting is not listed and specify the setting.
|
| Other Setting Description | Text |
Please provide a detailed description of the child's current setting. Fill only if 'Other, Specify Setting' is 'Yes'.
Depends on:
Other, Specify Setting
|
| DCFS Client Service Plan Request | ||
| DCFS Client Service Plan | Checkbox |
Check this box if a DCFS Client Service Plan is being requested as additional information.
|
| Foster Parent Information | ||
| Foster Parent Name(s) | Text |
Provide the full name(s) of the foster parent(s).
|
| Foster Parent Address | Text |
Enter the complete street address of the foster parent(s).
|
| Foster Parent Zip Code | Text |
Enter the five or nine-digit zip code for the foster parent's address.
|
| Foster Parent Phone Number | Text |
Provide the primary phone number for the foster parent(s), including the area code.
|
| Foster Parent Primary Language | Text |
Specify the primary language spoken by the foster parent(s).
|
| General | ||
| Text46 | Text | |
| Text47 | Text | |
| Text48 | Text | |
| Text49 | Text | |
| Text50 | Text | |
| Text51 | Text | |
| Text52 | Text | |
| Text53 | Text | |
| Text101 | Text | |
| Text102 | Text | |
| Text103 | Text | |
| Text104 | Text | |
| Text105 | Text | |
| Text105a | Text | |
| Text108 | Text | |
| Text109 | Text | |
| Text110 | Text | |
| Text111 | Text | |
| Text112 | Text | |
| Text113 | Text | |
| Text114 | Text | |
| Text115 | Text | |
| Text116 | Text | |
| Text117 | Text | |
| Text118 | Text | |
| Text119 | Text | |
| Home Available Days | ||
| S | Checkbox |
Check this box if the FP Home phone number is available on Sunday.
|
| M | Checkbox |
Check this box if the FP Home phone number is available on Monday.
|
| T | Checkbox |
Check this box if the FP Home phone number is available on Tuesday.
|
| W | Checkbox |
Check this box if the FP Home phone number is available on Wednesday.
|
| T | Checkbox |
Check this box if the FP Home phone number is available on Thursday.
|
| F | Checkbox |
Check this box if the FP Home phone number is available on Friday.
|
| S | Checkbox |
Check this box if the FP Home phone number is available on Saturday.
|
| Home Contact Information | ||
| Home Phone Number | Text |
Please provide the home phone number.
|
| Home Phone Best Time To Call Beginning | Time |
Please specify the beginning of the best time to call the home phone number. Fill only if 'Home Phone Number' is not empty.
Depends on:
Home Phone Number
|
| Home Phone Best Time To Call End | Time |
Please specify the end of the best time to call the home phone number. Fill only if 'Home Phone Number' is not empty.
Depends on:
Home Phone Number
|
| Initial Social History/Comprehensive Assessment/Addendums Request | ||
| Initial Social History/Comprehensive Assessment/Addendums | Checkbox |
Check this box if you are requesting the Initial Social History, Comprehensive Assessment, or any Addendums.
|
| Other Available Days | ||
| Sunday | Checkbox |
Check this box if Sunday is an available day to call for the 'FP Other' phone number.
|
| Monday | Checkbox |
Check this box if Monday is an available day to call for the 'FP Other' phone number.
|
| Tuesday | Checkbox |
Check this box if Tuesday is an available day to call for the 'FP Other' phone number.
|
| Wednesday | Checkbox |
Check this box if Wednesday is an available day to call for the 'FP Other' phone number.
|
| Thursday | Checkbox |
Check this box if Thursday is an available day to call for the 'FP Other' phone number.
|
| Friday | Checkbox |
Check this box if Friday is an available day to call for the 'FP Other' phone number.
|
| Saturday | Checkbox |
Check this box if Saturday is an available day to call for the 'FP Other' phone number.
|
| Other Contact Information | ||
| Other Phone Number | Text |
Please enter any other relevant phone number.
|
| Other Phone Best Call Time Start | Time |
Please enter the start time when the other contact phone number is best to call. Fill only if 'Other Phone Number' is not empty.
Depends on:
Other Phone Number
|
| Other Phone Best Call Time End | Time |
Please enter the end time when the other contact phone number is best to call. Fill only if 'Other Phone Number' is not empty.
Depends on:
Other Phone Number
|
| Other Information Request | ||
| Other Information Type | Checkbox |
Check this box if you are requesting additional information not covered by the other listed categories and specify the type of information needed.
|
| Other Information Type | Text |
Specify the type of other information being requested. Fill only if 'Other Information Type' is 'Yes'.
Depends on:
Other Information Type
|
| Page 3 | ||
| Additional Caseworker Information | Text |
Provide additional information collected directly from the referring caseworker, such as the type and frequency of services.
|
| Acceptance of the referral | Checkbox |
Check this box if the referral is accepted.
|
| Refer back to DCFS or foster care agency | Checkbox |
Check this box if the case is being referred back to DCFS or a foster care agency.
|
| Reason for Referral Back to Agency | Text |
Provide the reason(s) why the case is being referred back to DCFS or the foster care agency, including recommendations for service or intervention. Fill only if 'Refer back to DCFS or foster care agency' is 'Yes'.
Depends on:
Refer back to DCFS or foster care agency
|
| Placement Change Notice | ||
| Yes, 14 Day Notice Issued | Checkbox |
Check this box if a 14-day notice of placement change has been issued.
|
| No, 14 Day Notice Issued | Checkbox |
Check this box if a 14-day notice of placement change has not been issued.
|
| Prior Services | ||
| Counseling/Therapy | Checkbox |
Check this box if the child received counseling or therapy services in the last year.
|
| Tutoring | Checkbox |
Check this box if the child received tutoring services in the last year.
|
| Psychological Assessment | Checkbox |
Check this box if the child received a psychological assessment in the last year.
|
| Respite | Checkbox |
Check this box if the child received respite care services in the last year.
|
| Substance Abuse Treatment | Checkbox |
Check this box if the child received substance abuse treatment in the last year.
|
| Mentoring | Checkbox |
Check this box if the child received mentoring services in the last year.
|
| Speech/Occupational/Physical Therapy | Checkbox |
Check this box if the child received speech, occupational, or physical therapy services in the last year.
|
| Recreational (i.e., memberships) | Checkbox |
Check this box if the child participated in recreational activities (e.g., memberships) in the last year.
|
| Medical Assessment/Treatment (beyond routine care) | Checkbox |
Check this box if the child received medical assessment or treatment beyond routine care in the last year.
|
| Special Educational Services | Checkbox |
Check this box if the child received special educational services in the last year.
|
| SASS | Checkbox |
Check this box if the child received SASS (Screening, Assessment, and Support Services) in the last year.
|
| Provider and Child Information | ||
| Text57 | Text | |
| Text58 | Text | |
| Text59 | Text | |
| Psychological Assessments Request | ||
| Psychological Assessments | Checkbox |
Check this box if psychological assessments are being requested.
|
| Psychological Assessment Type | Text |
Please specify the type of psychological assessment requested. Fill only if 'Psychological Assessments' is 'Yes'.
Depends on:
Psychological Assessments
|
| Referral Description | ||
| Referral Description | Text |
Briefly describe the presenting issues that have caused you to seek assistance from IPS, state specifically what you are seeking from IPS, and include why the referral is being made now.
|
| Referral Information | ||
| Date of Referral | Date |
Please enter the date when the referral was made.
|
| LAN of Placement | Text |
Please enter the Local Area Number or identifier for the placement location.
|
| Release of Information Request | ||
| Release(s) of Information | Checkbox |
Check this box if you are requesting the release of confidential information.
|
| Stepping-Down Information | ||
| Future Setting | Text |
Enter the future setting for the child.
|
| Expected Step-Down Date | Date |
Provide the expected date for the child's step-down.
|
| Supervisor Information | ||
| Supervisor Name | Text |
Please enter the full name of the supervisor.
|
| Supervisor Phone | Text |
Please provide the phone number of the supervisor.
|
| Work Available Days | ||
| Sunday | Checkbox |
Check this box if work is available on Sunday.
|
| Monday | Checkbox |
Check this box if work is available on Monday.
|
| Tuesday | Checkbox |
Check this box if work is available on Tuesday.
|
| Wednesday | Checkbox |
Check this box if work is available on Wednesday.
|
| Thursday | Checkbox |
Check this box if work is available on Thursday.
|
| Friday | Checkbox |
Check this box if work is available on Friday.
|
| Saturday | Checkbox |
Check this box if work is available on Saturday.
|
| Work Contact Information | ||
| Work Phone Number | Text |
Please provide the work phone number.
|
| Work Call Start Time | Time |
Please enter the beginning time when contact can be made at work. Fill only if 'Work Phone Number' is not empty.
Depends on:
Work Phone Number
|
| Work Call End Time | Time |
Please enter the ending time when contact can be made at work. Fill only if 'Work Phone Number' is not empty.
Depends on:
Work Phone Number
|