Child Welfare
Child Well Being Program
Behavioral Rehabilitation Services (BRS)
Referral
Case/child information:
Date completed:
Child’s name:
Date of birth:
Prime number:
Case number:
Person number:
County of jurisdiction:
Caseworker name:
Email:
Phone:
FAX:
Supervisor:
Is this an ICWA case?
Yes
No
Child’s height:
Hair color:
Child’s weight:
Eye color:
Cultural identity:
Religion:
Race/ethnicity:
Sex:
Male
Female
Gender identity:
Male
Female
IQ:
Legal guardian name:
Legal status:
Email:
Phone:
FAX:
Child’s attorney:
Phone:
Is the child ISA Eligible? (Individual Service Array, a level of outpatient
mental health service through local mental health)
Ext.:
Ext.:
Ext.:
Yes
No
Unknown
Child and family team members, other individuals important to the child
Mother:
Father:
Siblings:
Phone:
CASA:
Physician:
Dentist:
Probation officer:
Wrap coordinator:
Therapist:
CCO:
Other:
Other:
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Phone:
Phone:
Ext.:
Ext.:
Phone:
Phone:
Phone:
Phone:
Phone:
Phone:
Phone:
Phone:
Phone:
Ext.:
Ext.:
Ext.:
Ext.:
Ext.:
Ext.:
Ext.:
Ext.:
Ext.:
CF 1055 (06/2014)
Childs current appointments and standing obligations:
Visitation with parents and siblings
When:
Mental health therapy appointment
When:
Medication management
When:
Upcoming court date
When:
Please list any other appointments with date, time and location below:
Where:
Where:
Where:
Where:
Documentation of the need for Behavioral Rehabilitation Services (BRS)
Child has two or more dysfunctional and debilitating psycho-social, emotional and/or behavioral
disorders and/or other problems that require BRS as indicated below. If applicable, please explain in
detail the behavior when it has occurred.
H = History of behavior
C = Current behavior (within 6 months) NA = Does not apply
Level of risk
H
C
NA
Behavior/need
Low
Average
High
Extreme
Fire setting/reckless
Please explain behavior in detail:
Cruelty to animals
Please explain behavior in detail:
Sexual acting out or reactivity
Please explain behavior in detail:
Aggressive/assaultive
Please explain behavior in detail:
Alcohol or drug abuse
Drug of choice and details of use patterns:
Enuresis/encopresis Frequency:
<1/wk
Has restraint been used due to safety issues:
Withdrawn/depressed:
Impulsive/unpredictable behavior:
Exposes self to harm:
Defiant of authority:
Serious property damage:
Victim of physical or sexual abuse:
Self-abusive behavior:
Anger management problem:
Excessively agitated/hyperactive:
Extreme difficulty staying on task:
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1-2/wk
3-5/wk
5+/wk
CF 1055 (06/2014)
Documentation of the need for Behavioral Rehabilitation Services (BRS)
Extreme demands for attention:
Extremely poor social skills:
Sleep disorders:
Runaway behavior:
Eating disorder:
Suicidal talk/ideation:
Threats of violence against others:
Extremely fearful/anxious:
Anti-social or delinquent behavior:
Academic problems/IEP (please specify current school setting):
Mainstream
Alternative
Contained classroom
Day treatment
H
C
NA Other presenting issues and medical needs
Gang affiliation:
Pregnant:
Parenting a child:
Hallucinations/delusional:
Use of tobacco:
Overweight/obese:
High blood pressure:
Diabetic:
Other (allergies, dietary concerns/restrictions etc.):
Child interests and strengths
Enjoys sports
Baseball
Artistic
Band
Enjoys music
Rock
Favorite subject
History
Favorite video game:
Favorite board game:
Other hobbies and interests:
Basketball
Drawing
Rap
Phys Ed
Football
Skating
Choir
Painting
Country
Hip-hop
Science
Literature
Favorite movie/genre:
Favorite book/magazine:
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Soccer
Drama
Pop
Math
CF 1055 (06/2014)
Executive functioning skills
N
R
S
O
U
N = Never R = Rarely S = Sometimes O = Often
Handles transitions well
Accurate assessment of time requirements
Completes tasks timely
Maintains focus during activities
Able to maintain focus when needed with other stimuli
(noises, people, etc) present.
Considers multiple solutions to a problem
U = Unknown
Language processing skills
Expresses thoughts and needs verbally
Understands spoken directions
Is able to follow conversations
Emotional regulation skills
Utilizes coping skills effectively when anxious
Manages disappointment in age appropriate way
Able to identify when they are frustrated, and calm before acting/making
a decision
Cognitive flexibility skills
Able to see “shades of gray” rather than “black and white”
Handles deviations from rules, routines and changes of plan
Interprets information accurately without over-generalizing
Able to envision different possibilities
Social skills
Pays attention to verbal and nonverbal cues
Accurately interprets nonverbal social cues
Engages peers appropriately
Seeks attention in appropriate ways
Understands how their behavior affects others
Shows empathy for others and their points of view
Reason for placement need:
Where is the child currently placed?
Why is the current placement disrupting?
When is placement needed by (please specify date)?
Please provide information regarding child specific triggers of anxiety, depression, anger etc.:
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CF 1055 (06/2014)
Reason for placement need:
Please provide information regarding the child’s coping skills, successful methods used to
de-escalate etc.:
BRS setting recommended for this child:
Residential
Therapeutic Foster Care (TFC)
If recommended for TFC placement, please check only if required:
One parent (male)
One parent (female)
Two parent
Must have own room
Other children in home must be:
Older
Younger
Age range:
Before submitting please attach copies of the following information:
DHS child specific case plan form 6723
DHS court order or voluntary custody or placement agreement, whichever is applicable
Most recent CANS assessment
Current IEP/3–year educational eligibility re-determination evaluation
Most recent psychological, psychiatric evaluation and assessments (i.e., drug and alcohol,
mental health, fire-setting psycho-sexual, and/or psycho–social assessment)
Any current services or conditions mandated by court (copy of probation order must
accompany this.)
Required signatures
Caseworker signature (required)
Date
Supervisor signature (required)
Date
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CF 1055 (06/2014)