Family Group Decision Making Conference Referral Formcfsmn.org/family_group_files/FGDM...

Community and Family Services, LLC • 1343 Heritage Drive • Waite Park MN 56387 Phone: 320.230.0900 • Fax: 320.230.0908 • Email: [email protected] • www.cfsmn.org

Family Group Decision Making ConferenceReferral Form

Referred by:___________________________________ Date:___________________ County/Agency:________________________________ Interpreter services needed: yes no If yes please list language or special need___________________________________________ Client:______________________________________ Home phone:______________ Address:_____________________________________ Work phone:________________ ____________________________________________ Work hours:_______________ ____________________________________________ Contact at work? yes no Children at risk: Date of birth: Location: (home, relative, foster care, etc.) __________________ ____________________ ____________________________ __________________ ____________________ ____________________________ __________________ ____________________ ____________________________ __________________ ____________________ ____________________________ __________________ ____________________ ____________________________ __________________ ____________________ ____________________________ __________________ ____________________ ____________________________ __________________ ____________________ ____________________________

Describe briefly how Social Services or the Agency became involved? Brief description of the reason for the Family Group Conference: Does the family agree about the issues/reasons? Family strengths: Are there other service providers or community people who have provided services to the family who would possibly like to be invited to the meeting? Please identify if there are any drug/alcohol problems in the family:





Are there any other special considerations or issues the facilitators need to be aware of? Please list dates and times youth, family members and agency workers are available or dates and times to avoid for the Family Group Conference and if weekdays or weeknights are preferred. The coordinator will arrange all the specifics this with the providers and the family. Thank you for filling out the above information. A coordinator from Community and Family Services, LLC will get back to you within 1-3 days to discuss this referral and start coordinating your Family Group Conference. If you have any questions or comments please feel free to contact Debbie Kasper at (320) 230-0900. This information can be sent to Community and Family Services, LLC, 1343 Heritage Drive, Waite Park, MN, 56387 or fax (320) 230-0908. Looking forward to working with you.


Family Group Decision Making ConferenceConsent To Release Information

I understand that a copy of the Family Plan that we create during the FGDM meeting will be distributed to all participants. This consent to release information will expire one year from the signature date unless I revoke this consent at any time by written notice sent to Community and Family Services. The information to be released is private and any further use is governed by the Minnesota Government Data Practices Act (MN Stat. Chap. 13). The agency, its contractors, or staff providing information are released from legal responsibility or liability for the release of information to the extent indicated and authorized herein.

Name (printed) Signature Date

I hereby authorize Community and Family Services, LLC - Family Group Decision Making (FGDM) program staff to exchange, release, disclose or obtain information and/or copies of all reports and documents about myself and my family to or from the following people for the purpose of planning, coordinating, and facilitating my FGDM meeting and for the purpose of creating a Family Plan for my child and our family. (Some people you may want to include are: extended family, close friends, chemical dependency counselor, social service case workers, mental health therapists, school counselors and/or special education staff, mentors, probation or parole officers, guardians ad litem, foster care providers, tribal representatives, etc.) I understand that some of the information discussed could be considered private and/or protected and I knowingly waive any rights to keep that information confidential in the course of this program.

Name

Name

Address Phone Relationship Community and Family Services, LLC

1343 Heritage Drive, Waite Park, MN 56387

(320) 230-0900 FGDM Provider


Family Group Decision Making ConferencePossible Matters To Consider

POSSIBLE MATTERS TO CONSIDER WHEN DEVELOPING FAMILY PLAN

Assistance with appointments

Safety/crisis plan

School enrollment and educational needs

Transportation

Counseling

Visitation coordination

Extended family involvement

Respite/daycare

Sibling contact

Living arrangements

Transition plan

Back-up plan

Who will monitor the Family Group Decision Making plan?


Family Group Decision Making ConferenceParticipation Guide

Why was I invited? You are involved in this family. The family is inviting people who know and care about them. They are facing some decisions about what is in the best interest of the child or children in their family. They would like your input and assistance in this effort. What is a Family Group Decision Making Conference? It is a unique meeting that respects family and friendship connections. We believe that families possess the greatest knowledge about themselves and have the greatest commitment to their family members. We believe in their ability to create a successful family plan. This is a meeting to look for and build on family strengths. Strengths are what help to resolve issues of concern and ease worries. You can help by telling of the strengths that you notice in this family. Also, please be prepared to share honestly about any worries that you might have for this family. Information sharing: Family members meet with friends, community members, and professionals to share strengths, concerns/needs, and ideas or resources. It is your opportunity to share your perception of family strengths and worries. Typically, information sharing lasts about an hour. Facilitators have the task of setting both the pace and the tone of the meeting. Please do not be offended by their directive to remain focused on the conference process and limited agenda. Prior to the service providers leaving the room any required bottom lines and/or available resources will be shared.

Family time: Typically, family members meet in private. During this time service providers may be asked to step out of the room; however, they will be available for questions. The family has the option to request the assistance of the neutral facilitators if the family thinks it is needed. The family’s task is to review the information provided during information sharing and develop a family plan that keeps the child (ren)'s best interests and safety as the main objectives. The family may want to identify someone within the family to monitor the family progress with their plan. Closure: The conference facilitators and service providers rejoin the family to review the family plan. This is an opportunity to fine-tune the details of the plan. The assigned social worker has an obligation to make sure that the family plan ensures the safety of the children. It must also meet the conditions of any existing juvenile/adult court order. If necessary, in court involved cases, the social worker may assist the family in presenting their family plan to the court. Otherwise, the family is encouraged to begin their good work on a plan that they have developed for themselves and their child (ren).

Below are some ideas to be thinking about prior to the conference. This guide is just for you. You may bring it to the meeting. Some people find it helpful to jot down ideas prior to coming and others find it helpful to share their thoughts as they come at the time of the meeting. The child(ren)’s and family strengths/things that are going well: Concern(s) you may have for the child(ren) or family: Safety and stability: What ideas/resources do you have for solutions to the above concerns? What might be helpful? How do you see yourself as being part of the plan and playing a role in the solutions?


Family Group Decision Making ConferenceParticipation Guide


Family Group Decision Making ConferenceFor Those Unable To Attend

It is unfortunate that all those invited to the Family Group Decision Making Conference are not able to attend. Because your input is important to the process, we ask that you complete the following questions and return this as soon as possible, so that your comments can be shared at the conference. What are the strengths that you see in the family members and in the family as a whole? These can be things like personality characteristics, motivations, interests, and/or anything that you feel is a positive that you would like shared at the meeting. What are the concerns for the children, family members and/or for the family? What needs do you see? Do you have safety, mental health, or physical health concerns? What ideas do you have for solutions to the above concerns? What might be helpful, are there services you would suggest? Do you want to be a part of the plan and how do you see yourself playing a role in the solutions?


Family Group Decision Making ConferenceFor Those Unable To Attend

Additional comments to be shared at the meeting? _________________________________________ ______________________ Your Name Date _________________________________________ Family/Child (ren) Names of Group Conference If you have any questions please feel free to call us at (320) 230-0900. In the enclosed self addressed envelop please return to: Community and Family Services, LLC Attn: Group Facilitators 1343 Heritage Drive Waite Park, MN 56387 Or fax it to our agency at (320) 230-0908

Family Group Decision Making Conference Referral Formcfsmn.org/family_group_files/FGDM...

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