CST Care Coordination Referral Form - Child Advocates of Fort Bend

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CST Care Coordination Referral Form

REFERRAL SOURCE INFORMATION

Referral Agency/Organization

Name *

First

Last

Phone *

Email *

Date of Referral

Is the Referral Urgent? *

Yes
No

If urgent, please explain:

YOUTH/CHILD INFORMATION

Name *

First

Last

Preferred Name/Nickname

Date of Birth

Gender

Male
Female

Ethnicity/Race

Primary Language

Current Location/Placement

Parent/Guardian
Foster Care
Kinship Placement
Residential Treatment Center
Juvenile Detention
Other, explain below

Address (if known)

Address Line 1

Address Line 2

City

State

Zip Code

School/Grade (if applicable)

CAREGIVER/GUARDIAN INFORMATION

Name

First

Last

Relationship to Child

Phone

Email

Is the Caregiver Aware of the Referral

Yes
No

DFPS/LEGAL INVOLVEMENT

Is the child involved with DFPS?

Yes
No
Unknown

If yes, please indicate DFPS case number:

Caseworker Name

First

Last

Caseworker Phone

Caseworker Email

Supervisor Name (if known)

First

Last

Supervisor Email (if known)

Supervisor Phone (if known)

Stage of Case

Investigation
Conservatorship
Family-Based Safety Services

Legal / Law Enforcement Involvement

Is there active Law Enforcement involvement?

Yes
No
Unknown

If yes, Law Enforcement Agency:

Law Enforcement Case Number:

Detective/Officer Name:

First

Last

Detective/Officer Phone

Detective/Officer Email

Additional Legal Parties

Attorney ad Litem / CASA involved?

Yes
No
Unknown

DFPS/LEGAL INVOLVEMENT

If Yes - Attorney Name

First

Last

Attorney Phone

Attorney Email

CASA Name

First

Last

CASA Phone

CASA Email

Juvenile Probation involvement?

Yes
No

If Yes, Probation Officer Name

First

Last

Probation Officer Phone

Probation Officer Email

TRAFFICKING CONCERNS/INDICATORS

Reason for referral (choose all that apply)

Confirmed victim of sex trafficking
Suspected victim of sex trafficking
High-risk behaviors/indicators
Running away / frequent missing episodes
Inappropriate relationships with older individuals
Online exploitation concerns
Prior trafficking history
Other

Brief description of concerns

SAFETY ASSESSMENT

Has a CSE-IT screening been completed?

Yes
No
Unknown

CSE-IT score:

Immediate Safety Concerns

Has a report been made to the Texas Abuse Hotline?

Yes
No

Intake Report #

CURRENT SERVICES & SUPPORTS

Is the child currently receiving services?

Yes
No

If yes, please list:

Therapy Provider

Case Management

Medical Services

Other

REQUESTED SUPPORT FROM CARE COORDINATION

choose all that apply

Multidisciplinary Care Coordination
Case Staffing
Service Navigation
Advocacy Support
Safety Planning
Training/Consultation
CSE-IT Screening
Other, explain below

Name the If

ADDITIONAL INFORMATION

Please include any relevant history, behavioral concerns, triggers, strengths, or other information that will assist the Care Coordination team:

CONSENT & INFORMATION SHARING

Has appropriate consent been obtained to share this information?

Yes
No

Are there any limitations to information sharing?

Yes
No

If yes, please explain

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5403 Avenue N,
Rosenberg, TX 77471

Phone: 281-344-5100

Hours:
Monday – Thursday: 8am until 6:30pm
Friday: 8am until 12pm

Mailing Address:
P.O. Box 8,
Richmond, TX 77406

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Child Advocates of Fort Bend is a 501(c)(3) nonprofit organization.