Family First Prevention Services Act

Download a Referral for Qualified Individual Assessment and send via email to:

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.

  1. Signed BHRS Release of Information (PDF)
  2. Signed BHRS Consent to Treatment Forms (PDF)
  3. Child Welfare/Juvenile Probation Case Plan (including Permanency Plan)
  4. 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.

  1. List of services that have been provided to preserve the current placement, including child welfare funded services and interventions
  2. CFT Recommendations (if applicable)
  3. JV 220 (if applicable)
  4. Psychological Evaluations
  5. Any current family visitation orders including no contact orders
  6. Education information including current IEP or 504 plan if applicable (Health and Education Passport)
  7. Placement History including successful placements and services printed out from CWS/CMS – full history
  8. Medical history including medical hospitalizations (Health and Education Passport)
  9. Psychological Evaluations
  10. Pathway to Wellbeing Screening 
  11. CANS Screening Tool
  12. 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
  13. Juvenile Probation specific assessments and latest social studies report
  14. 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
  15. Mental Health Plan Clinician- Psychological Evaluations
  16. Mental Health Plan Clinician- History of Psychiatric Hospitalizations

Send a Referral for Qualified Individual Assessment to

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: