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- Contract Program referring to*
- CSL Program referring to:*
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- Restitution owed?*
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- Is client in the community or detention at this time?*
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- Date of Birth*
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- Legal Sex*
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- Is FFT:*
- Re-Referral?*
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- Reason for referral:*
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Format: (000) 000-0000.
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- Are there any Protective or No Contact orders in place for this family/client:*
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- Has the client been placed outside the home in the last 90 days?*
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- Current Legal Status:*
- Is JSC Case Summary attached*
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- Probation Requirements*
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- if IDA score is none or low, Due to FFPSA dollars has your supervisor approved FFT for this client?
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- Are there any safety concerns in the home?*
- Suspected Gang Affiliation:*
- Are there firearms in the home?*
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- Should be Empty: