Amara

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*  
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?*
Has the caregiver been made aware of the referral?*
If extended family is involved, have they been made aware of the referral?
Child/Youth Info
Youth First Name*
Youth Last Name*
Birth Date* Calendar
Original Placement Date* Calendar
Date youth first was placed in out-of-home care
Date placed with current caregiver* Calendar
Famlink ID*
Race/Ethnicity*
 
Does child have siblings?*
Is Child Placed with Siblings?  
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)?  
*If so, which agency provides this and who your contact at the ESIT agency?
*Are services provided with parent, caregiver or both?
 
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*  
How did you hear about FCP?*
 
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?
 
DCYF Social Worker’s name and email*
DCYF Unit*  
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)?*  
Today's Date* Calendar
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*
 
Language Translation Needed?*  
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
 
Language Translation Needed?  
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*
 
Language Translation Needed?*  
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