FAMILY NAME: FIRST SCREENING DATE:
IDCFS
Statewide Legal Screening Form
WORKER:
AGENCY:
ADDRESS:
PHONE: Fax:
DATE THIS CASEWORKER ASSIGNED:
SUPERVISOR’S NAME, PHONE & Fax:
I. BACKGROUND INFORMATION ON
THE CHILD
Name on
birth certificate & AKA's
DOB: Gender:
Juvenile
Court Case No: Court Calendar (for Cook
County Cases):
DCFS ID
#: Court County (outside of Cook County):
Reason
for initial removal/protective custody
Name of
Guardian (DCFS or other
Date of
Guardianship/Disposition:
Finding/Adjudication:
Neglect Abuse Dependency
Date of
finding
Name & address of Guardian ad litem
Name & address of mother’s attorney:
Name & address of father’s attorney:
Has
this child previously been adopted or had a subsidized guardian? Yes No
If the child was adopted, was the child from a
foreign country? Yes No
If yes, which country?
Has this case been taken through the legal screening
process in the past? Yes No
On what date did the court change the goal away from
return home?
What is the next court date?
If there has been a Permanency Hearing on this case,
what is the court-set goal?
What was the date of the last Permanency Hearing?
On what date is the next Permanency Hearing?
If there has been no Permanency
Hearing yet, what is the agency-set permanency goal for this child?
CFS
1427 (6/03)
Is this child of American Indian Ancestry? Yes No Tribe
·
If so, please attach all correspondence with the child’s
tribe
INFORMATION ON ALL OTHER SIBLINGS:
NAME AGE AGENCY Reason(s) Not Being
Screened
Are there new siblings not yet screened into care?
Have you discussed screening the siblings with
their worker?
When?
II. BIRTH PARENT INFORMATION
Birth
Mother:
Address/City/Zip
Code:
Telephone:
Date of
Birth: Social Security Number:
Is the
birth mother deceased? Yes No
If yes,
attach a copy of the death certificate.
Has the
birth mother ever been married? If so,
to whom & dates of marriage/s:
Is the
birth mother divorced? Yes No If yes, include a copy of the divorce decree.
·If the birth mother’s
whereabouts are unknown, you must attach a completed Diligent Search Request and Response.
·In
Cook County, attach all supporting documentation.
Has the birth mother ever had any contact with the
child? Yes No
If so, what was the date of the birth mother’s last
contact with the child?
Type of
contact (ex: visit, phone call, letter):
Frequency
of contact:
Did the
birth mother sign a specific consent to adoption? Yes No
If so,
date:
Or, did
the birth mother sign a surrender of parental rights for purposes of
adoption?
Yes No If yes, on what date?
·If
either a consent or surrender was signed, attach a copy.
Has the
birth mother ever had any contact with you or any caseworker? Yes No
If so,
when did the mother last have contact with you or any caseworker?
Birth
Father:
Telephone:
Date of
Birth: Social Security Number:
Is the
birth father deceased? Yes No If yes, attach a copy of the death
certificate.
Has the
birth father ever been married? If so,
to whom & dates of marriage/s:
Is the
birth father divorced? Yes No If yes, include a copy of the divorce
decree.
·If the birth father’s
whereabouts are unknown, you must attach a completed Diligent Search Request and Response.
·In
Cook County, attach all supporting documentation.
Has the birth father ever had any contact with the
child? Yes No
If so, what was the date of the birth father’s last
contact with the child?
Type of
contact (ex: visit, phone call, letter):
Frequency
of contact:
Did the
birth father sign a specific consent to adoption? Yes No If so, date:
Or, did
the birth father sign a surrender of parental rights for purposes of
adoption?
Yes No
If yes, on what date?
·If
either a consent or surrender was signed, attach a copy.
Has the
birth father ever had any contact with you or any caseworker? Yes No
If so,
when did the father last have contact with you or any caseworker?
Putative Father:
Name
& AKA’s:
Telephone:
Date of
Birth: Social Security Number:
Is the
birth father deceased? Yes No If yes, attach a copy of the death
certificate.
Has the
birth father ever been married? If so,
to whom & dates of marriage/s:
Is the
birth father divorced? Yes No If yes, include a copy of the divorce decree.
·If the birth father’s
whereabouts are unknown, you must attach a completed Diligent Search Request and Response.
·In
Cook County, attach all supporting documentation.
Has the birth father ever had any contact with the
child? Yes No
If so, what was the date of the birth father’s last
contact with the child?
Type of
contact (ex: visit, phone call, letter):
Frequency
of contact:
Did the
birth father sign a specific consent to adoption? Yes No
If so, date:
Or, did
the birth father sign a surrender of parental rights for purposes of
adoption?
Yes No
If yes, on what date?
·If
either a consent or surrender was signed, attach a copy.
Has the
birth father ever had any contact with you or any caseworker? Yes No
If so, when did the father last have contact with you or
any caseworker?
MISCELLANEOUS
DOCUMENTATION
Putative
Father Registry search:
·
A Putative Father Registry (PFR) search must be done for
virtually all children. An exception
would be if there were a finding of paternity based upon a DNA test, or if the
father is named on the birth certificate and he was married to the mother at
the time of birth or conception and his name is also on a marriage
certificate.
·
Once a PFR is completed and a response is received, it is
good forever and need not be done again, as long as you still have the
response.
·
NOTE: If a
diligent search has been made for the father and is still current, the Diligent
Search Service Center will check the Putative Father Registry as part of it’s
search, so you need not check the PFR in these cases.
III. ATTEMPTS TOWARD REUNIFICATION
What services has mother failed
to complete? (Note: “None” or “All” is not a complete answer)
List each task from
client service plan.
What services has father failed
to complete? (Note: “None” or “All” is not a complete answer)
List each task from
client service plan.
What services has mother
successfully completed? (Note: “None” or “All” is not a complete answer)
List each task from
client service plan. DESCRIBE MOTHER’S
VISITATION HISTORY.
What services has father
successfully completed? (Note: “None or All” is not a complete answer)
List each task from
client service plan. DESCRIBE FATHER’S
VISITATION HISTORY.
For Termination of Parental
Rights/Adoption cases only, ATTACH A LIST OF ALL OUTSIDE AGENCIES THAT THE
PARENTS WERE REFERRED TO, THEIR ADDRESSES, AND THE REASONS FOR THE REFERRALS.
IV.
MISCELLANEOUS
INFORMATION ON BIRTH PARENTS
·
Skip this section if this is a Subsidized
Guardianship case or Expedited Adoption case.
Has any
parent been convicted of a crime
involving child abuse, drugs, and/or violence?
Yes No
Who &
When?
Explain:
Is any parent addicted to drugs, and/or alcohol?
Who?
Explain:
Has any sibling died as a result of abuse? Yes No
Who & when?
Explain:
Is there any evidence of mental
illness in the parents of the child? Yes No
Who?
Explain:
Other information regarding fitness of parent(s). Include prior
history of voluntary or involuntary termination.
V.
BEST
INTEREST ISSUES
DO NOT INCLUDE ADDRESS OF
FOSTER PARENT/CAREGIVER
Foster
parent/Caregiver(s):
DATE OF PLACEMENT IN CURRENT
HOME:
Divorced? Widowed? Never married?
Married? Separated If separated, for how long?
Occupation:
Employer
Occupation: Employer:
Age: Age:
Is this a relative
placement? Yes No
If so, what is the relationship?
Is the home licensed? Yes No
Is this an adoptive home? Yes No
Note: There must have been a family
meeting with the caregiver prior to screening to discuss the possibility of
adoption, and to complete form CFS 1443 Permanency Commitment by Foster
Parent/Relative Caregiver. If the
caregiver is unsure about adoption, every effort should be made to answer the
caregiver’s questions and resolve their concerns prior to legal screening.
Does the caregiver have any health related problems? Yes No
If so, provide details
What is the caregiver’s backup plan in the event of
illness, disability or death?
Is the person named in the backup plan in agreement with
the plan?
What is the back up caregiver’s current involvement with
the child/ren?
What is your placement recommendation?
How often do you visit the home? Date of the last visit:
Does anyone else live in home other than the minor
and foster parent(s)? Yes No
If yes,
who? List names, ages and relationship to the caregiver:
Have you done CANTS/LEADS
on all adults in the home? Yes No
·
If yes, when was this last done?
Does anyone in the foster home
have a criminal background? Yes No
·
If so, attach complete description/printout and
explanations.
Have there been any Unusual
Incident Reports on the foster home?
Yes No
If yes, attach all UIR’s (CANTS 52 form): Dates:
Have
there been any indicated reports of abuse or neglect on anyone in foster home?
Yes No If
so, attach description and explanations.
Are there any indications of risk to the child in
the home? Yes No
If yes,
describe in detail:
Are there any other problems in the home? Yes No
If yes,
describe in detail :
DOES THIS CHILD WISH TO BE
ADOPTED? Yes No
Other comments:
HAS
ANYONE ELSE, including family members,
EXPRESSED AN INTEREST IN ADOPTING THIS CHILD?
Yes No
If yes,
please explain who and when:
B) IF
THE CHILD IS NOT IN AN ADOPTIVE HOME
How bonded is the child to the foster parent and how long has the
child been in the home?
What is the foster parent’s reason for not adopting?
Is there a relative of the foster parent or child, or friend of the
family interested in adoption?
Yes No
If so, who?
When will you list the child
with the Adoption Information Center of Illinois, if you haven’t already done
so?
What have you done to find an adoptive home?
How many families have you successfully contacted
regarding adoption of this child?
Have you explored permanency
where siblings are placed? Yes No
If not, why not
On what date was the most recent family meeting held with an adoption
worker and the foster family?
Who attended?
Step 1:
Certification and Recommendation by Caseworker and Supervisor
All the information provided in
this packet is accurate and complete, to the best of our knowledge. No pertinent information has knowingly been
withheld.
IT IS IN THE BEST INTERESTS OF
THE CHILD THAT PERMANENCY BE ACHIEVED IN THIS CASE.
Caseworker’s
Signature Supervisor’s
Signature
Type or
Print Name Type
or Print Name
Date Date
Step 2: Review & Approval by DCFS
OLS Field Paralegal and/or Regional Counsel:
I have
examined this screening packet and supporting documentation prepared by the
caseworker, and, to the best of my knowledge based on the information provided,
it is accurately prepared and complete for submission for legal screening.
NOTE: Approval by OLS of this screening packet
does not indicate that this case has “PASSED” legal screening. Refer to your “OLS Legal Screening
Pass/Hold” sheet for information on whether this case has passed legal
screening.
Approved
by Office of Legal Services Date
Type or
Print Name and Title
For
Cook County Expedited
Adoption Cases Only:
Step 3 – Approval by POS Adoption
Liaison/DCFS Adoption Supervisor
The Adoption Assistance
Agreement/s for the child/ren achieving permanency includes thorough
information regarding current services, clinical and medical diagnoses and
assessments, pre-existing conditions and the circumstances of how the child/ren
came into State care.
The subsidy has been completed and
typed Yes No
The Investigatory Report is signed
and dated,
and is comprehensive and complete.
Yes No
The foster parents have
preliminarily approved the subsidy: Yes No
The caseworker and supervisor have
preliminarily
I have reviewed this case and
subsidy, and based upon the information provided to me, approve it as an adoptive placement.
POS Adoption Liaison/DCFS Adoption Supervisor
signature Date
WITNESS/CASEWORKER LIST (for Termination of Parental Rights/Adoption
Cases only):
NAME AGENCY
PHONE NUMBER
I, ,
a caseworker for
(agency
name), under oath, pursuant to the penalties set out in 735 ILCS 5/1-109,
certify that I have prepared and read the attached “IDCFS Statewide Legal
Screening Form” and certify that the information contained therein is correct
and true to the best of my knowledge and belief.
Current
Caseworker Signature Date
Legal
Screening Form: Instructions:
Legal
Screening is necessary to determine whether the filing of a termination of
parental rights petition is warranted, or another permanency option is
appropriate, and if so, to ensure the successful prosecution of the termination
petition.
It is
vitally important that workers prepare their packets as thoroughly as possible
and be as forthcoming as possible so that the screeners can make an appropriate
decision.
Caseworkers must thoroughly review the agency’s file and the child’s
court file (located in the Clerk’s Office at Court) prior to submitting their
request form for screening. Frequently,
vital information has been found in the court file that requires additional
work and delay in filing the termination petition.
PREPARATION OF A SCREENING PACKET
1. Read through
this entire form first.
2. Please fill the form in
COMPLETELY. For example, do not put
“N/A” for the last contact that the mother/father had with the child. Indicate a date. If the last time that a parent visited was when the child was
born, please state so.
3. When putting your packet together, put the documents in
the order listed in the checklist at the beginning of the packet. Staple or rubber band each section
individually and rubber band the entire packet.
For Cook County Expedited Adoption Cases Only:
After
the case has been screened and approved by DCFS Office of Legal Services,
proceed to
Screening with your POS Adoption Liaison or DCFS
Adoption Supervisor. For each child
being adopted, you will need the following documents (typed and signed):
Five
subsidies with original signatures, signed by the caregiver/s & agency
·
Include all
supporting documentation
Affidavit of
Agency Expenses
Entry of
Appearance
Special
Needs Certificate
Agency
Consent to Adoption if parents no longer
have rights,
For example, if parent signed a Surrender; or parents’ rights
have been terminated by termination order.
SUBMIT
TWO COPIES/SETS OF YOUR COMPLETED SCREENING FORM and retain a copy for
yourself.