- Home
- Services
- Departments & Services A-G
- Behavioral Health & Recovery Services
- Family First Prevention Services Act
Family First Prevention Services Act
- Family First Prevention Services Act (FFPSA) Requirements (PDF) - IN 21-055
- View the Qualified Individual Brochure
- Assessments by a Qualified Individual (QI) for placements in Short-Term Residential Therapeutic Program (STRTP)
- FFPSA Part IV Aftercare Requirements IN 21-061
Download a Referral for Qualified Individual Assessment and send via email to: FFPSAQIReferral@countyofmerced.com.
Documents identified below are required and must accompany the QI Referral form. Placing agencies are required to provide an explanation for any documentation that is not attached to the QI referral.
- Signed BHRS Release of Information (PDF)
- Signed BHRS Consent to Treatment Forms (PDF)
- Child Welfare/Juvenile Probation Case Plan (including Permanency Plan)
- Needs and Services Plan from current placement provider (if applicable)
Mental Health Plan Clinician - Most Recent Mental Health Assessment (Completed in the last 12 months)
Mental Health Plan Clinician - Most Recent Mental Health Treatment Plan
Most Recent Completed CANS to be completed by appropriate agency's staff
Additional documentation to ensure a complete and comprehensive QI assessment, may be included at the time of the referral by the Placing Agency Social Worker/Probation. All items must be provided to the QI but are not required to be attached to the QI Referral form.
- List of services that have been provided to preserve the current placement, including child welfare funded services and interventions
- CFT Recommendations (if applicable)
- JV 220 (if applicable)
- Psychological Evaluations
- Any current family visitation orders including no contact orders
- Education information including current IEP or 504 plan if applicable (Health and Education Passport)
- Placement History including successful placements and services printed out from CWS/CMS – full history
- Medical history including medical hospitalizations (Health and Education Passport)
- Psychological Evaluations
- Pathway to Wellbeing Screening
- CANS Screening Tool
- Developmental Assessment if applicable including documentation related to both being assessed for and receiving services authorized through a Regional Center or provided by a Regional Center vendor
- Juvenile Probation specific assessments and latest social studies report
- Mental Health Plan Clinician – List of services that have been provided during the prior 12 months (at a minimum), including wraparound and Specialty Mental Health Services
- Mental Health Plan Clinician- Psychological Evaluations
- Mental Health Plan Clinician- History of Psychiatric Hospitalizations
Send a Referral for Qualified Individual Assessment to FFPSAQIReferral@countyofmerced.com.
Please Note: Once a completed Referral for Qualified Individual Assessment is received, the process for completing the comprehensive assessment and recommendations may take up to thirty (30) days.
Questions related to the FFPSA Referral for QI Assessment and/or process, please email: FFPSAQIReferral@countyofmerced.com.