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:

 

Name & AKA’s:

                                                                                                                                                              

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:

 

Name & AKA’s:

                                                                                                                                                              

Address/City/Zip:

                                                                                                                                                              

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:

Address/City/Zip:                                                                                                                                   

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

A)        FOSTER PARENT/CAREGIVER HOME INFORMATION

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

approved the subsidy                                                                                  Yes  No

 

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

 

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

                                                                                                                                                              

 


CERTIFICATION

 

 

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


IDCFS Office of Legal Services

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.