Instructions: This form is to be used in making an initial referral to County Department(s), recording date and outcome of review by county and for making referral to the State Conflict Resolution Team (CRT).

Identifying Information

1.	Name of Person making the referral:	__________________________________________________
	Complete mailing address of person making the referral:	__________________________________________________
	Daytime phone number of person making the referral (include area code):	___________________________________________________
	E-mail address of Person making the referral	___________________________________________________

2.	Person making the referral is:	Foster Parent	County Supervisor
		Social Worker	Foster Parent Liaison
		Other, please identify role ____________________________________

3.	Foster parent is approved by____________________ County DHR Child/sib group involved is in custody of ________________________________________________________________________________________

4.	Children Involved:
	Full Name	Birthdate	Full Name	Birthdate
	_______________________________	___________	________________________________	___________
	_______________________________	___________	________________________________	___________
	_______________________________	___________	________________________________	___________
	_______________________________	___________	________________________________	___________
	_______________________________	___________	________________________________	___________

Your complaint deals with:

Problem with communication between line worker and the foster parent – lack of courtesy, respect, professionalism in communication such as failing to return phone calls, failure to listen to concerns, etc.

Lack of responsiveness to requests by the foster parent for assistance in dealing with the children in care

Removal of children without due notice according to applicable policies and standards

Issues of potential safety risks to children

Failure to follow policies

Failure to arrange needed services for the child/foster family

Failure to schedule an ISP as requested

Situations where the foster parent or SDHR has identified trends by county as it relates to appropriate grievance issues

Closure of a home by DHR

Failure to abide by provisions of Foster Parent Bill of Rights. Specify which provisions: ______________________________________

_____________________________________________________________________________________________

Other ________________________________________________________________________________

5.	In a BRIEF PARAGRAPH summarize your complaint and your desired outcome for this referral (do not simply say, “see attached documentation”). *Attach supporting documentation to this referral form.

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Documentation of local review:

Date referral initially made with the local agency:________________

Referral was filed initially with:__________________________________________

Name of Person(s)

__________________________________________

Position of Person(s)

Referral was ______hand delivered _____sent US mail ______sent via email

If a local review was conducted (meeting held) date of meeting:__________________

Briefly describe outcome of meeting:___________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

___________________________________ _________________________________________

Signature person making the CRT referral Signature local review liaison or meeting facilitator

If resolution was not reached at the local level and a review by the State Conflict Team is desired, person making referral should mail this form to: State of Alabama Department of Human Resources

Gordon Persons Building

Family Services Division, Office of Permanency

ATTN: CRT liaison

50 Ripley Street

Montgomery, Al 36130

Upon the liaison’s receipt of this referral form an acknowledgement letter will be sent and requests for records made. State CRT members and others will be notified of referral and notification of next standing meeting date will be provided.