Family & Community Connections Program Intake Form
Thank you for submitting your referral to the Family & Community Connections Program! Our program coordinator is out this week, so we may have a slight delay and in processing these referrals. We will do our best to follow up with you in a timely manner. If you need immediate assistance regarding your referral, please email fcp@amarafamily.org.
Case Information
DCYF Case ID #
*
Referring Court
*
Chelan County
Clark Co Best for Babies
Clark County
Cowlitz Co
Gray's Harbor
Grays Harbor Co – Family Therapeutic Court
King Co – Family Treatment Court
King County
Kitsap County
Kitsap Safe Baby Court
Mason Co – Family Reunification Court
Mason County
Okanogan Co – Family Treatment Court
Okanogan Co FTC
Pacific Co FRC
Pacific County
Pierce Co Best for Babies
Pierce Co FTC
Pierce County
Skagit County
Skamania County
Snohomish
Spokane
Thurston Co
Thurston Co. - Safe Baby Court
Tribal office - no county
Whitman County
Yakima
Family Treatment Court Identifier, if applicable
*
Are all clients aware of referral?
We ask that both the parent(s) and caregiver(s) (or whoever will be participating in this FCCP case) are made aware of the FCCP referral before/at the time of sending the intake info back. Please answer the questions below:
Has the parent been made aware of the referral?
*
Yes
No
Has the caregiver been made aware of the referral?
*
Yes
No
If extended family is involved, have they been made aware of the referral?
Yes
No
Child/Youth Info
Youth First Name
*
Youth Last Name
*
Birth Date
*
Original Placement Date
*
Date placed with current caregiver
*
Famlink ID
*
Race/Ethnicity
*
Arab, Iranian or Middle Eastern
Asian
Black/African American
Hispanic or Latino
Multi-Racial
Native American or Alaska Native
Other
Pacific Islander or Native Hawaiian
Unknown
White
Does child have siblings?
*
Yes
No
Is Child Placed with Siblings?
All
N/A
None
Some
If child has siblings, please list their names here
Early Support for Infants and Toddlers (ESIT)
For children 3 and under only: Is child engaged in an Early Support for Infants and Toddlers program (ESIT aka Birth to Three aka Early Intervention)?
Yes
No
Not sure
*If so, which agency provides this and who your contact at the ESIT agency?
*Are services provided with parent, caregiver or both?
Caregiver(s)
Parent(s)
Referral Info
What is your goal or hope in getting this family connected to FCCP?
*
What is the current relationship between the potential participants in the program? Are they in communication? If so, how often and in what format? Is there additional history that would be helpful for us to know?
Your role
*
Amara
Caregiver
CFWS
CPS/FVS/FRS
DOC
ECC Coordinator
ESIT provider
GAL/CASA
Other
Parent
Parent Ally
Parent Attorney
How did you hear about FCCP?
*
Amara staff member
colleague
FCCP Flyer/Rack Card
FCCP Newsletter
Other
presentation to your staff
supervisor
Any safety concerns we should be aware of prior to scheduling a Connections Conversation (no contact orders, sex offender registration status, restrictions on caregiver/parent contact)?
*
What type of Connection is this?
Connection (new or any stage of the placement)
Extended Family
Light Conflict Resolution
Transition/Reunification
DCYF Social Worker’s name and email
*
DCYF Unit
*
101229964
101658799
101748104
103477455
104221761
104435097
104747100
2497896
2963344
Aberdeen
Arlington
Bellingham
Bremerton
Centralia
Choices: Amara Relinquishment
Clark Co Best for Babies
Clark County - FTC
Clark County – Cascade
Clark County – Columbia
Clark County- Clark
Clarkston
Colfax
Colville
Delridge
Ellensburg
Enumclaw
Everett
Forks
Friday Harbor
Goldendale
Grays Harbor Co FRC
Head Quarters - (OB-2)
Kelso
King Co FTC
King East DCFS
King East/Bellevue
King South- West
King South/Kent
King South-east
King South-West
King West DCFS
King West/Harrison
Lakewood
Local Private Agency
Long Beach
Lynnwood
Martin Luther King Jr. Office
Mason Co FRC
MLK
Monroe
Moses Lake
Mount Vernon
Mt Vernon
Newport
Oak Harbor
Office of Indian Child Welfare - R04
OICW
Okanogan Co FTC
Olympia DCFS (Tumwater)
Omak
Oregon DHS
Out of State - California
Out of State Govt Agency
Out of State Private Agency
Pacific Co FRC
Parkland
Pierce Co Best for Babies
Pierce Co FTC
pierce county
Pierce East
Pierce South
Pierce West
Port Angeles
Port Townsend
Primary Worker Office Name
Puyallup
Puyallup Office
Region 2 Adoptions
Region 3 Adoptions
Region 4 Adoptions
Region 4 Family Treatment Court
Region 4 Office
Region 5 Adoptions
Region 5 Office
Region 6 Adoptions
Region 6 Centralized Services
Republic/Union
Richland
Shelton
Sky Valley
Smokey Point
South Bend
South Pierce County
Spokane
Stevenson
Sunnyside
Tacoma
Tacoma Office
Toppenish
Tri-Cities
Tumwater
Vancouver
Vancouver - Cascade
Vancouver - Columbia
Walla Walla
Wenatchee
West Seattle DCFS
White Center
White Salmon
Yakima
Does parent prefer a mentor of a particular gender due to DV or other trauma (we will make our best attempt to provide this whenever possible)?
*
Female-identifying
Male-identifying
No preference
Unknown
Today's Date
*
Parent 1
Please fill out as much information as you have so our team can contact the parents
Parent Name
*
Parent 1 Phone
Enter International
Parent 1 Email
Parent 1 Race
*
Arab, Iranian or Middle Eastern
Asian
Black/African American
Hispanic or Latino
Multi-Racial
Native American or Alaska Native
Other
Pacific Islander or Native Hawaiian
Unknown
White
Language Translation Needed?
*
Yes
No
Unknown
Parent 1 Attorney (name and email)
*
Parent 2
if applicable
Parent 2 Name
Parent 2 Phone
Enter International
Parent 2 Email
Parent 2 Race
Arab, Iranian or Middle Eastern
Asian
Black/African American
Hispanic or Latino
Multi-Racial
Native American or Alaska Native
Other
Pacific Islander or Native Hawaiian
Unknown
White
Language Translation Needed?
Yes
No
Unknown
Parent 2 Attorney (name and email)
Caregiver Info
Caregiver Name
*
Caregiver Phone
*
Enter International
Caregiver email
*
Caregiver relationship to child
*
Caregiver race
*
Arab, Iranian or Middle Eastern
Asian
Black/African American
Hispanic or Latino
Multi-Racial
Native American or Alaska Native
Other
Pacific Islander or Native Hawaiian
Unknown
White
Language Translation Needed?
*
Yes
No
Unknown
Submit