Welcome to your Circuit 17 Resource Page. Here you will find various forms, tools, community resources and contacts specific to child welfare staff in Broward County. We encourage you to check back here often to view forms and resources that have been recommeded for this page by your local administrators.

Circuit 17 Key Contacts

Silvia Beebe
Circuit Community Development Administrator
FL Department of Children and Families
1400 W Commercial Blvd, Room 210c
Ft. Lauderdale, Fl 33309
Dennis Miles
Interim Regional Managing Director
Circuits 15 & 17
111 S. Sapodilla Ave
West Palm Beach, Fl  33401
(561) 837-5078
Kim Gorshuch, MSW, Dir of BSO CPIS
Child Protective Investigations Section
Broward County Sheriff’s Office
1415 W Cypress Creek Road, Suite 100
Fort Lauderdale, FL 33309
Emilio Benitez
President and CEO
ChildNet Inc.
313 N State Road 7
Plantation, Fl 33317
Circuit 17

Broward Sheriff's Office Forms

2012-2013 Request for TANF Funds-Eligilibity Determination
At-Risk Child Care Application and Authorization
BSO Critical Incident Report
Child Case Closure Checklist
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)
Commercially Sexually Exploited Child / Human Trafficking Multi-Disciplinary Safe Harbor Assessment Report (March 2014)
Consent to the Release of Information (CPIS 119-Feb 2013)
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 Assisstance or Waiver Form (May 2011)
DCF FSFN Safety Plan
Dear Relative Care Giver EPSDT Letter (March 2013)
Dependency-Criminal Joint Investigation Form (School Board)
Direct Supervision Verification Form (Dec, 2014)
Human Trafficking Screening Tool Instructions
Institutional Investigation Safety Planning Form
Multi-System Staffing Team (MSST) Report-Vulnerable Teens (March 2014)
National Youth Advocate Program (NYAP) Kinship Referral Form
Non-Relative Caregiver Financial Assistance Application
Random Drug Testing Authorization Form-Hire Image (June 2015)
Request for Medical Examiners’ Autopsy Report
School Board of Broward County Release Form-Taking a Dependent Child Into Custody
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
Women in Distress Referral for Services (Creole)
Women in Distress Referral for Services (Spanish)
Emergency Removal Packet

1-Case Opening Document-Case Staffing Form (CPIS 122-Aug 2013)
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)
5-Notification to Placement Unit for Detained Children Not in DCF Shelter Placement (CPIS 130-Jan 2017)
6-Notice of Commencement of LiveScan-Background Screening (CPIS 180-May 2013)
7-Request for Legal Action on Adjudicated Dependent Children (Feb 2013)
8-Parental Authorization for Contined Provision of Psychotropic Medication
9-Consent to the Release of Information (CPIS 119-Feb 2013)
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)
Transformation Forms

Child Present Danger Assessment (July 2013)
Child Safety Plan (July 2013)
Information Collection and Family Functioning Assessment (July 2013)
HEART Alliance

HEART Alliance for Sustainable Families Information Sheet
HEART Alliance Family Stories
Training Materials

Understanding Safety Threats In-Service Training (Jan 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)
Circuit 17 Prevention Plan (2010-2015)
Interim Report of the Spring Term 2001 Grand Jury
Tri-County OTI and Case Transfer Protocol -Southern and Southeast Region (Feb'11)
School Information
Broward County School Calendar (2015-2016)
Broward County Schools - Alpha List (2015-2016)
Broward County Schools - Charter School List (2015-2016)
Broward County Schools - Opening and Closing School Times(2015-2016)
Other Resources
Broward Behavioral Health Coalition Consumer Handbook (2014)
CBC Lead Agency Operations, Adoptions and Program Contacts
Local Services Directory
Transportation Disadvantaged Application
Treatment Directory for Children with Sexual Behavior Problems and Child Sexual Abuse Victims