Ranch Ehrlo Society Treatment Foster Care Program (TFCP ... · Please provide a physical description of the child (i.e., height, weight, eye colour, hair, scars, birthmarks, ... Phone

1 | P a g e T r e a t m e n t F o s t e r C a r e P r o g r a m – R e f e r r a l I n f o r m a t i o n F o r m

Ranch Ehrlo Society

Treatment Foster Care Program (TFCP)

Referral Information Form

Does this referral meet the TFCP criteria? (Use check boxes below to assess suitability against criteria.)

• The child requires specialized treatment within a family environment.

• The child can be cared for safely in a treatment foster family residing in the community.

Criteria:

☐ The child does not exhibit at-risk behaviours requiring 24/7 intensive supervision, support and care;

☐ The child does not exhibit aggressive behaviours that pose a significant threat to the welfare of other children or adults;

☐ The child does not exhibit severe physical, mental, or developmental issues requiring an alternative treatment resource;

☐ This is not a referral for long-term foster care. There are plans to reunite the child with family or transition the child to extended family or a foster family within 24 months;

☐ The child, parents, extended family members, or caregiver(s) identified are aware of and open to the possible transition plan(s);

☐ The parents or caregivers identified in the transition plan are willing to participate in the pre-intake and intake meetings and to work with the treatment foster care parents and program.

Date: Click or tap here to enter text.

Part One -- PRIMARY REFERRAL

Name of Child: Click or tap here to enter text.

Date of Birth: use format 01-JANUARY-2000) Click or tap here to enter text.

Place of Birth: Click or tap here to enter text.

Health Card Number: Click or tap here to enter text.

Treaty Card Number: Click or tap here to enter text.

Status: (i.e., Ward, Parental Agreement, etc.) Click or tap here to enter text. (Please attach copy of scanned

agreement with this form.)

Current Placement: Click or tap here to enter text.

Length of Stay: Click or tap here to enter text.


Is English the child’s first language: ☐ Yes ☐ No

If not, what language is spoken at home? Click or tap here to enter text.

Please provide a physical description of the child (i.e., height, weight, eye colour, hair, scars, birthmarks,

tattoos, etc.)

Click or tap here to enter text.

Part Two – REFERENT INFORMATION

Name of Referent: Click or tap here to enter text.

Referral Date: Click or tap here to enter text.

Phone number(s): Office Click or tap here to enter text. Cellular Click or tap here to enter text.

Email address: Click or tap here to enter text.

MSS Supervisor: Click or tap here to enter text.

MSS Supervisor Phone number: Click or tap here to enter text.

Part Three – FUNDING INFORMATION

Treatment Foster Care invoice to: Click or tap here to enter text.

Is placement at Ranch Ehrlo School requested? ☐ Yes ☐ No

If yes, Education invoices sent to: ☐ ICFS Agency ☐ Province of Saskatchewan

☐ Other (please indicate):


Part Four – FAMILY / CAREGIVERS IDENTIFIED FOR REUNIFICATION

Name of Mother / Maternal Caregiver: Click or tap here to enter text.

Mother’s Maiden Name (if different from above): Click or tap here to enter text.

Date of Birth: Click or tap here to enter text.

Address: Click or tap here to enter text.

Phone number (include area code): Click or tap here to enter text.

Employer and occupation: Click or tap here to enter text.


Describe the relationship with their child and their interest in reunification:


Name of Father / Paternal Caregiver: Click or tap here to enter text.

Date of Birth: Click or tap here to enter text.


Phone number (include area code): Click or tap here to enter text.

Employer and occupation: Click or tap here to enter text.

Describe the relationship with their child and their interest in reunification:


Siblings and/or Significant Others:

Name Relationship Location Contact (Yes or No)

Part Five – CAREGIVER RISK FACTORS

(Check your response) 0 (no risk) to 3 (high risk) 9 (unknown)

Substance Abuse ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Mental, emotional, intellectual or physical impairment ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Parental skills / expectations of child ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Empathy / nurturing / bonding ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

History of violence or sexual assault ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Protection of child by non-abusive caretaker ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9


Recognition of problem / motivation to change ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Level of co-operation ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Familial, Social and Economic Factors

(Check your response) 0 (no risk) to 3 (high risk) 9 (unknown)

Substance Abuse ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Mental, emotional, intellectual or physical impairment ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Parental skills / expectations of child ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Empathy / nurturing / bonding ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

History of violence or sexual assault ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Protection of child by non-abusive caretaker ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Recognition of problem / motivation to change ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Level of co-operation ☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 9

Have other family members been explored as a potential placement? Click or tap here to enter text.

Additional Family Information (any comments regarding strengths, challenges, or information not already

documented):


Part Six – MEDICAL HISTORY

PLEASE INCLUDE A COPY OF THE IMMUNIZATION RECORDS (scan and email as attachment).

Medical Issues (please describe):

Please check all that apply:

☐ Allergies ☐ Asthma ☐ Dental Problems ☐ Disabilities

☐ Seizures ☐ Immunizations ☐ Diabetes ☐ Bleeding / Bruising

If any of the boxes above are checked, please explain / describe:



☐ Medications (list and explain): Click or tap here to enter text.

☐ Infectious diseases: Click or tap here to enter text.

☐ Other (explain / describe in detail): Click or tap here to enter text.

Name Phone number (include area code)

Last appointment

Next appointment

Physician

Dentist

Optical

Specialist

Specialist

Does the child have any suspected or confirmed developmental problems (i.e., fetal alcohol exposure, ADHD,

etc.)?


Has the child been hospitalized since birth? ☐ Yes ☐ No ☐ Unknown

If yes, please describe reason(s):


Solvent / Drug Abuse History

Does the child use tobacco? ☐ Yes ☐ No ☐ Unknown

Does the child use alcohol, drugs or solvents? ☐ Yes ☐ No ☐ Unknown

If yes, describe usage, age at which the use started, frequency and extent:


Describe the pattern of alcohol and drug use within the family system:



Part Seven – EDUCATION

Please attach any available information regarding the child / youth’s education (i.e., academic testing,

behavioural problems, suspensions, letters from teachers, etc. Please scan and email as attachment).

Last school attended: Click or tap here to enter text.


Teacher’s name: Click or tap here to enter text.

Program or grade level: Click or tap here to enter text.

Describe the child’s attitude towards school and behavior while in school:


Describe the child’s academic progress:


Other schools attended:

Name of School (and location) Date(s) of attendance Grade

Part Eight – PLACEMENT HISTORY

List all placements that the youth has been in (foster homes, group homes, custody facilities, relatives, etc.)

Please fill out the table below with details of placements.

Placement type (foster home, etc.)

Dates Reason for Move Other necessary information


Community

Has the child been involved in illegal activity? ☐ Yes ☐ No ☐ Unknown

Have the police become involved? ☐ Yes ☐ No ☐ Unknown

If yes, list charges, court dates, and dispositions and attach relevant documentation (i.e., undertaking,

probation, community service orders, subpoena to witness, etc.).


Community involvement (please list participation, including social groups, recreational, employment,

volunteer, etc.)


Describe the child’s peers and/or peer group(s):


Describe current placement information (i.e., functioning, daily routines, interests, areas of strengths,

challenges, etc.)


Please list the child’s major strengths:


Please list the child’s major needs:


Does the child show interest and motivation for living with a treatment foster family?



What are the major issues for service and / or referent expectations while at Ranch Ehrlo for the child / youth

and for the family?

Major Issue for Service Referent’s Expectation

1.

2.

3.

4.

5.

What is the anticipated period of treatment? Click or tap here to enter text.

Part Nine – SUPPORTING INFORMATION (DOCUMENTATION AND ASSESSMENTS)

The following information is required prior to the child / youth’s placement in our program. (Please attach /

provide.)

• Health Service card and number

• Band Treaty Number (if applicable)

• Birth Certificate

• Wardship documentation (Section 9, Long Term Order, etc.)

• Copy of Probation Order, Undertaking, etc.

• Ministry Child Assessment and Development Plan

• Ministry Assessment and Case Plan

• Child Welfare Investigation Plan

Please attach copies of the following assessments, if they have been completed.

• Educational and Psychological Assessments

• Psychiatric Assessments

• Comprehensive Social History

• Family Assessments

• Addictions Assessment (where applicable)

• Other (please describe) Click or tap here to enter text.


Section Ten – REFERENT INFORMATION AND COMPLETION INSTRUCTIONS

Name of Referent: Click or tap here to enter text.


Signature: Click or tap here to enter text.

Name of Referent’s Supervisor: Click or tap here to enter text.


Signature: Click or tap here to enter text.

PLEASE SIGN FORWARD THIS COMPLETED REFERRAL FORM AND ALL INFORMATION / SUPPORTING

DOCUMENTATION TO:

RANCH EHRLO SOCIETY, Intake Committee

PO Box 570

Pilot Butte, SK S0G 3Z0

Attention: David Rivers, Director

Email: [email protected]

Tel: (306) 781-1800

Fax: (306) 757-0599

You will be contacted to confirm receipt of this referral.

Documents

Ranch Ehrlo Society Treatment Foster Care Program (TFCP ... · Please provide a physical description of the child (i.e., height, weight, eye colour, hair, scars, birthmarks, ... Phone