Knowledge & Information Distribution Site (KIDS)
Circuit 17
Forms, Tools, Community Resources, Contacts and Community Links
Circuit 17 Key Contacts
Dawn Liberta
Circuit Community Development Administrator
FL Department of Children and Families
1400 W Commercial Blvd, Room 210c
Ft. Lauderdale, Fl 33309
954-375-6092
Dennis Miles
Regional Managing Director
Circuits 15, 17 & 19
111 S. Sapodilla Ave
West Palm Beach, Fl 33401
561-227-6779
Captain Edward McCardle
Director of BSO CPIS
Child Protective Investigations Section
Broward County Sheriff’s Office
1415 W Cypress Creek Road, Suite 100
Fort Lauderdale, FL 33309
954-308-0607
Larry Rein
Chief Executive Officer and President ChildNet Inc.
1100 West McNab Road
Fort Lauderdale, Fl 33309
954-414-6000
Broward Sheriff's Office Forms
2012-2013 Request for TANF Funds/Eligibility Determination
At-Risk Child Care Application and Authorization
Child Find / FDLRS Referral Form 0-5
Child Protection Rights and Responsibilities
Child Protection Rights and Responsibilities - Creole
Child Protection Rights and Responsibilities - Spanish
COC Multi-Disciplinary Staffing Form (July 2012)
Consent to the Release of Information (CPIS 119-Jan.2019)
CSC & Non-CSC Family Strengthening Referral (Feb 2014)
Customer or Companion Communication Assessment and Auxiliary Aid/Service Form (Rev. May 2011)
Customer or Companion Request for Free Communication Assistance or Waiver Form (May 2011)
Dear Relative Care Giver EPSDT Letter (March 2013)
Dependency-Criminal Joint Investigation Form (School Board)
Direct Supervision Verification Form (Dec, 2014)
Early Steps Referral for Developmental Assessment Birth-3 years old
Healthy Start Connect Referral Form
Human Trafficking Multidisciplinary Staffing Form
Human Trafficking Screening Tool Instructions
Institutional Investigation Safety Planning Form
Multi-System Staffing Team (MSST) Report-Vulnerable Teens
National Youth Advocate Program (NYAP) Kinship Referral Form
Non-Relative Caregiver Financial Assistance Application
Phamatech Drug Testing Referral Form
R&R Domestic Services, Inc.- Batterers’ Intervention Referral Form
Request for Medical Examiners’ Autopsy Report
School Board of Broward County Release Form-Taking a Dependent Child Into Custody
SMART Team Referral (Dec 2016)
Substance Exposed Infant Multi-disciplinary Staffing Form (July 2012)
Unified Home Study (Final-April 2013)
Verification of Indian Child Form Instructions (CS-FSP 5323)
Verification of Indian Child Welfare Act Eligibility (CF-FSP 5323)
Women in Distress Referral for Services
Emergency Removal Packet
1-Case Opening Document (Dec 2017)
2-Placement Referral Child Detail-One for Each Child (CPIS 176-May 2013)
3-Placement Referral Caregiver Detail-One for Each Caregiver (May 2013)
4-CPIS Removals-Change of Placement (CPIS 156-Feb 2013)
6-Notice of Commencement of Live Scan / Background Screening (CPIS 180-May 2013)
7-Request for Legal Action on Adjudicated Dependent Children (Feb 2013)
8-Parental Authorization for Continued Provision of Psychotropic Medication
9-Consent to the Release of Information (CPIS 119-Feb. 2018)
10-Consent For Treatment and Release of Medical-Educational Records
11-Verification of Indian Child Welfare Act Eligibility (CS-FSP 5323)
12-Instructions for Verification of Indian Child Form (CS-FSP 5323)
13-Unified Home Study (Final-April 2013)
14-Dear Relative Care Giver EPSDT Letter (March 2013)
15-Consent for Medical Examination Care and-or Treatment (May 2013)
16-Consent to the Release of Information Related to Service Case Record (March 2013)
17-Acknowledgement of Firearms Safety Requirements (CF-FSP 5343, 2010)
18-Broward County Schools and BSO-CPI Caregiver Checklist (October 2017)
19-BSO-CPI Broward County School Transportation Request (October 2017)
20-School Stability Checklist for Children in Out-of-Home Care
Transformation Forms
Child Present Danger Assessment (July 2013)
Information Collection and Family Functioning Assessment (July 2013)
Additional Circuit 17 Resources
Protocols and Reports
Administrative Order - Child and Sexual Abuse Victims Interviews of Young Victims
Administrative Order - Unified Family Court
Administrative Order - Voluntary Dependency Drug Court Program
Circuit 17 Family Preservation Protocol Approval (memo July '10)
Circuit 17 Protocol for Preventive Family Preservation Services with Imminent Risk Cases (2010)
Interim Report of the Spring Term 2001 Grand Jury
Tri-County OTI and Case Transfer Protocol -Southern and Southeast Region (Feb'11)
