Date of Referral:

Reason for Referral: Policy 209	Placement/Community Resource	Consultation

Name of Youth:	D.O.B.:

CCRT Referral submitted by:

(Name)	(Division)

Involved Divisions:	DFS	Case Manager/Supervisor:

DPBHS	Team Leader/Regional Supervisor:

DYRS	Case Manager/Supervisor:

Legal Custodian:	Permanency Goal:

Other Team Members (e.g. CASA, GAL, Therapist, etc.):

Youth’s Pending Legal Charges and History of Adjudicated Charges:

Date of Next Court Hearing (if applicable):

Youth’s Current Location:	Anticipated Date of Discharge:

Youth’s Educational Status: Regular Education	Special Education

Youth/Family Strengths:

Individualized Needs (Cultural, Linguistic, Gender, etc.):

Barriers to locating appropriate services:

Details of Support/Service Provided: Placement	Community	Other

Division Perspective(s):

DFS:
DPBHS:
DYRS:

Please check which of the following have occurred:

DSCYF Team/Service Planning Meeting	Date	Plan/Summary Note Attached

Family Planning Meeting	Date	Plan/Summary Note Attached

(Include TDM or FIRST, if applicable)

Family Search and Engagement	Date	Summary Note Attached

*Please attach the following (if applicable):

Residential and community based service history, service plans(s), most recent assessments, and other applicable documentation such as:

Assessment for Residential Treatment (ART)

Court Orders

Placement Authorization Committee (PAC) decisions

Level of Care (LOC)/Search Flow

Utilization Reviews (URs)

Child Service Plan

List of current referrals and outcomes

Division Signatures for Active Divisions (live, e-mail endorsement or electronic signatures are acceptable):

Division	Title	Signature	Date
DFS	Assistant or Regional Administrator
DPBHS	Regional Supervisor for Team Leader
DYRS	Regional Manager

E-mail referral to CCRT Division Representative: http://extranet.kids.state.de.us/kids/information/ccrt.shtml