Santa Cruz — SUPCR-1136

Source: https://www.santacruz.courts.ca.gov/system/files/forms-and-filings/post-supcr-1136-family-preservation-court-referral-form.pdf

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ COLLABORATIVE COURTS OFFICE 701 OCEAN STREET SANTA CRUZ, CA 95060 (831) 420-2498 www.santacruzcourt.org

Family Preservation Court Referral

Client Name: Date of Referral:

DOB: Gender: Phone number:

Referral Source Name: Referral Source Phone Number: Interpreter: ☐ Yes ☐No Language:

Dependency Case Number: Parents Provided Services: ☐ Mother ☐ Father

Children’s Name & DOB: Parents relationship status: ☐ Intact ☐ Not intact

Six-Month Dependency Review Hearing date:

Name of Social Worker Assigned:

Current Case Progression Status: ☐Investigation & Dates: SUDS: Name of SUDS Coordinator:☐Jurisdiction Order Date:

☐ Dispositional Order: SUDS Assessment Status and Location: ☐ Residential ☐ IOPWIC Code: ☐ OP Dependency Case Status: ☐ Family Reunification Check the box for the Current resources being ☐ Family Maintenance accessed and list provider: ☐ Parents Center:☐ Bypass ☐ Unknown ☐ Leaps & Bounds:

Form Adopted for OPTIONAL USE FAMILY PRESERVATION COURT Page 1 of 2 Superior Court of Santa Cruz County REFERRAL SUPCR 1136 07/01/2025

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CRUZ COLLABORATIVE COURTS OFFICE 701 OCEAN STREET SANTA CRUZ, CA 95060 (831) 420-2498 www.santacruzcourt.org

☐ Parent Mentor Team: Employment: Employed: ☐ Yes ☐ No ☐ Other: Work Schedule: Do you have Medi-Cal: ☐ Yes ☐No ☐ Don’t know ☐Monday Primary Care Provider: ☐Tuesday ☐Wednesday ☐Thursday Housing Status: ☐Friday ☐Shelter ☐Street/Outdoors ☐ Housed ☐Saturday ☐Don’t Know ☐Sunday Hours per week: Transportation: Do you have reliable transportation: ☐ Yes ☐ No

Additional information:

Form Adopted for OPTIONAL USE FAMILY PRESERVATION COURT Page 2 of 2 Superior Court of Santa Cruz County REFERRAL SUPCR 1136 07/01/2025