Family Connections Program Intake Form

Thank you for filling out the Family Connections Program Intake Form! Please provide as much information as possible, but we understand there may occasionally be some you do not have. If this is the case, feel free to leave that space blank. If you have any questions, feel free to contact our FCP coordinator Fiona at FCP@amarafamily.org

Case Information DCYF Case ID #* Referring Court* Clark Co Best for Babies Clark County Gray's Harbor Grays Harbor Co – Family Therapeutic Court King Co – Family Treatment Court King 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 Skamania County Snohomish Tribal office - no county   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 FCP case) are made aware of the FCP 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? YesNo Has the caregiver been made aware of the referral? YesNo If extended family is involved, have they been made aware of the referral? YesNo Child/Youth Info Youth First Name* Youth Last Name* Birth Date* Original Placement Date* Date youth first was placed in out-of-home care 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?* YesNo 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)   check both boxes if services are provided to both

Referral Info What is your goal or hope in getting this family connected to FCP?* Your role Amara SW Caregiver CASA DCYF SW ESIT provider Other Parent   How did you hear about FCP?* Amara staff member colleague FCP Flyer/Rack Card FCP Newsletter Other presentation to your staff supervisor   Any safety concerns we should be aware of prior to scheduling a Connections Conversation (no contact orders, 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   Today's Date* DCYF Social Worker’s name and email* DCYF Unit* 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 Kelso King Co FTC King East/Bellevue King South- West King South/Kent King South-east King West/Harrison Lakewood Local Private Agency Long Beach Lynnwood Mason Co FRC MLK Monroe Moses Lake Mount Vernon Mt Vernon Newport Oak Harbor OICW Okanogan Co FTC 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 Puyallup Republic/Union Richland Shelton Sky Valley Smokey Point South Bend South Pierce County Spokane Stevenson Sunnyside Tacoma Toppenish Tumwater Vancouver Walla Walla Wenatchee 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   Parent 1 Please fill out as much information as you have so our team can contact the parents Parent Name* Parent 1 Phone ()-ext Enter Int'l Number 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 ()-ext Enter Int'l Number 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* ()-ext Enter Int'l Number 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

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