Child Welfare Services Referral Face Sheet
Safety Plan Services	FSRP Services	Parent Partners	FTDM or YTDM Meeting

I. Case Information

Referral Date

Case ID

State ID

Youngest Child Victim Name

FACS ID

Race

Ethnicity

Date of Birth (DOB)

County of Residence

Reason for Referral:
Document safety concerns and/or risk factors for the child/youth or family. List any concerns or issues relevant to case planning with this family:

II. DHS Referral Worker, DHS Social Work Case Manager (SWCM), and Supervisor Information

Referral Worker Name

Referral Worker Contact Number

Referral Worker Email Address

Assigned SWCM Name

SWCM Office Address

SWCM Contact Number and Extension

Fax Number

SWCM Email Address

SWCM Supervisor

Phone Number and Extension

Email Address

III. Family Information

Name of Parent

FACS ID

Race

Ethnicity

Name of Parent

FACS ID

Race

Ethnicity

Family Address

Family Contact Number (Phone/Cell)

Is the youngest child victim in an out-of-home placement?

Yes	No	Date of Removal from Home

Name of Placement

Is there a current Family Interaction Plan?

Yes	No
Address of Placement

Type of Placement

Phone Number of Placement

Contact Person Name

IV. Family Composition

Role	Name
(last, first)	DOB	Race/ Ethnicty	Contact
(Must be seen)	Frequency and Method of Contact (in person, phone, web, etc.)	Relationship to Youngest Child Victim	Address and Phone
Parent in the Home	/	Yes

No
Parent in the Home	/	Yes

No
Caretaking Adult	/	Yes

No
Caretaking Adult	/	Yes

No
Child (Youngest Child Victim Name)	/	Yes

No
Child (Victim or CINA)	/	Yes

No
Child (Victim or CINA)	/	Yes

No
Child (Victim or CINA)	/	Yes

No
Child (Sibling/ Household)	/	Yes

No
Child (Sibling/ Household)	/	Yes

No
Child (Sibling/ Household)	/	Yes

No
Child (Sibling/ Household)	/	Yes

No
Parent Not Residing in Home	/	Yes

No
Parent Not Residing in Home	/	Yes

No
For Safety Plan Services: The frequency of contact with the child victims and parents is daily face-to-face and with siblings and others as listed above.

For FSRP Services: The frequency of contact listed above is in effect until a FTDM or YTDM meeting is held or when the Case Plan is developed (no more than 60 days from initiation of services).

Safety Plan Services

Describe applicable service expectations and interventions below that are necessary to address identified safety concerns:

Safety checks and supervision activities:

Basic education for household management:

Transportation assistance:

Funding for concrete supports and connection to community resources:

Monitoring of mental health or substance abuse:

Inspection and monitoring home safety:

Other or additional information:

Family Safety, Risk, and Permanency (FSRP) Services

FTDM or YTDM Meetings and Court Involvement

Meeting/Hearing	Most Recent Date	Next Scheduled Date	County of Court Jurisdiction
Juvenile Court:
FTDM Meeting:
YTDM Meeting:
Is there a No Contact Order (NCO) in place?

Yes	No	If yes, between who?
Current Services and Supports

Type of Service or Support	Name of Contact Person,
Address, and Phone	Date Services
or Supports Began
Domestic Violence (DV)
Substance abuse (SA)
Mental health (MH)
Parent partner
Behavioral health intervention services (BHIS)
Integrated health homes (IHH)
Adult probation or parole
(requirements)
Treatment court
Parent Partners

Participant Family Information

Referred Participant Name (last, first)

Referred Participant Name (last, first)

County of Court Jurisdiction

Have the participants been involved in child protective services before?	Yes	No

Do the participants know a referral was made to Parent Partners?	Yes	No
Family Team Decision-Making (FTDM) or Youth Transition Decision-Making (YTDM) Meeting

Type of referral: FTDM meeting	YTDM meeting
Open FSRP services case	Non-FSRP services case
Life of the Case Juncture (Complete only if an open DHS child welfare service case):
For FTDM meeting:

Before removal	After removal

Placement change	Level of care change	Permanency decisions are made

Prior to case closure

Agency request
For YTDM meeting:

Within 30 days of youth’s 17th birthday

Within 90 days prior to youth’s 18th birthday

Check the boxes that apply.
Yes	No	Was there a prior FTDM or YTDM meeting? Date:
Yes	No	Is the family/youth aware a facilitator will be contacting them?
Yes	No	Is court involved? If yes, provide:
Date

Time

Type of Next Hearing

Yes	No	Is there a No Contact Order in place?
If yes, between who?
Are separate meetings required? Yes	No
Yes	No	Any cultural needs and/or special accommodations?
If yes, identify:
Yes	No	Need a translator or interpreter? Language:
Yes	No	Is there a current Family Interaction Plan developed and in place?
Yes	No	Is there a formal documented concurrent plan?

What is the desired outcome of this meeting?
(Development or review of: Family Plan, Case Plan, Family Interaction Plan, Concurrent Planning, etc.)

V. Potential Team Members

Member	Name	Email	Phone
DHS Social Work Case Manager (SWCM)
Child Protection Worker (CPW)
FSRP Services Care Coordinator
Child’s Attorney/GAL
CASA
Mother’s Attorney
Father’s Attorney
Parent Partner
Resource Family
Relative/Kinship Caregiver
Family Supports
Other/Role
Other/Role

Attachments to this referral face sheet:
Attached	Not Available
3055
CPW Safety Plan (Safety Plan Services and FSRP Services, if applicable)
Current Case Plan
Most recent Court Order (if applicable)
Child Abuse Assessment Summary Report/CINA Assessment Summary Report
Family Interaction Plan (if applicable and completed)
FTDM or YTDM Meeting Notes

470-5150 (Rev. 4/19)	Page 2 of 6

470-5150 (Rev. 4/19)	Page 1 of 6

470-5150 Child Welfare Services Referral Face Sheet

470-5150, Child Welfare Services Referral Face Sheet

Rev. 4/19

Yeager, Ronda

2019-07-01

Kristie Oliver

17-App., Mindy Norwood

State of Iowa - DHS