Welcome to the Circuit 4 Resources Page.  Information found here is specific to Circuit 4 users for your convenience and easy navigation.  Below you will find access links to specific information for Clay, Duval and Nassau Counties including various forms, tools, community resources, contacts and community links. 

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Circuit 4 Key Contacts

DCF Circuit 4
Patricia Medlock, Interim Regional Managing Director
5920 Arlington Expressway,
Jacksonville, FL, 2211-0083
(904) 723-2050, Ext 12,
Fax: (904)723-2000

Bryan Hensley
Circuit Community Development Administrator
Phone: (904) 485-9563
Fax: (904) 723-5389

CBC Lead Agency Administration
(Clay County)
Kids First of Florida
Irene Toto, CEO
1726 Kingsley Ave. Suite 2
Orange Park, Fl 32073
(904) 278-5644 Ext. 2005

(Duval and Nassau County)
Family Support Services of North Florida Inc.
Lee Kaywork, CEO
1300 Riverplace Blvd, Suite 700
Jacksonville, Fl 32207
(904) 421-5800

Circuit 4 Forms

Forms - Legal
Affidavit for Psychotropic Medication (6-09)
Affidavit In Compliance with Uniform Child Custody Jurisdiction
Emergency Intake Form
Emergency Motion to Modify Custody
Family Placement Tree
Legal Action Memo
Motion for Order to Take Into Custody
Order on Emergency Motion for Temporary Change of Placement
Order to Take Child Into Custody
Forms - Staffing
Red Flag Protocol
Red Flag Screening Checklist
Service Planning Conference Checklist
Forms - Referrals
211 Family and Parent Information Guide
Child Guidance Supervised Visitation Center/ Parenting
Child Victim Rapid Response Program
Comprehensive Behavioral Health Assessment/Referral
DCF Referral Form
False Reporting Referral
FIS Services Referral (11-09)
Full Services Schools Referral Form (print only)
Healthy Families Jacksonville Information Sheet
Healthy Families Jacksonville Referral Form
Hubbard House Referral
JCC Provider Information Form
Parent Aide Program
Referral to State Attorney
The Azalea Project (print only)
The Magnolia Project (print only)
TPC/New Beginnings
Youth Crisis Center Referral Form (Jan'10)
YCC-Project Second Chance Referral and Risk Analysis (Jan'10)
Forms - Other (A - L)
Abuse Notification
Acknowledgement of Receipt - Red Folder
Affidavit of Understanding
Background History Check Form
Caregiver Home Study
Child In Care Medicaid Application (2-09)
Collateral Matrix
Community Support Agreement
Consent for Treatment and Release of Medical Information
CPI Interview Checklist
DCF Incident Form
Emergency Shelter Checklist
Family Preservation Protocol 2-10-11
FDLE/Missing Child Reporting Form
Fire Rescue Report Request (print only)
FSW Service Request Form
HIPPA Acknowledgement
Judicial Involvement Closure Letter
Kids in Care 72 Hour Appointment Request Form
Letter of Authorization (1-11)
Forms - Other (M - Z)
Medical Release Form (1-11)
Multi-Disciplinary Questionnaire (1-11)
No Services Closure Letter
Procedure for Parenting Refusing to Accept Child (Lockout)
Protocol for Domestic Violence Investigations - Duval Co (12-08)
Protocol for Immediate CPT Staffings
Protocol for Investigating Public School Personnel
Prescribing Psychotropic Medication Children in Out-of-Home Care MEDICAL REPORT (CF-FSP 5339) (01/10)
Psychotherapeutic Medication Treatment Plan Review (FSP-5279) (09/10)
Request for Medical Records (no parent signature needed) (1-11)
STEPS & Other Services Closure Letter
Verification of Indian Child Welfare Act Eligibility
Voluntary Protective Supervision Agreement
YCC - Project Second Chance Program Description (6-09)
Circuit 4 Multimedia

Family Support Services Cassat House Video (Short Version) - Click here to play in your web browser

Download MPEG Video(62 MB)
Right-click link and select "save target as" to download.

Circuit 4 Resources

Local Resources
Circuit 4 Resources Listing (updated October 2009)
Provides local provider information for housing, food, clothing, substance abuse, mental health, and other resources for families
Boot Camp for New Dads
Florida Baptist Children's Home Safe Families Brochure
Foster Closet
a free resource for foster parents and relative and non-relative placements to access clothing, children's accessories, toys and children's furniture to help take care of the foster children entrusted to them.
Jacksonville Urban League Early Head Start Brochure
Link to United Ways of NE Florida - 211
Parenting Classes Matrix (Feb'10)
Parenting Program Brochure
Ungovernable/CINS/FINS Resource Listing (Nov'10)
Automated Community Connection to Economic Self-Sufficiency (ACCESS)
ACCESS Benefits Application
Direct link to application for Food Stamps, Medicaid, and Temporary Cash Assistance
ACCESS Community Partner Listing
Search for Community Access site in your area
ACCESS Florida Home Page
General information and links for the ACCESS program
Local Contacts
CBC Lead Agency Operations, Adoptions and Program Contacts
Local Services Directory
Disaster Preparedness - Emergency Management Plan
CPI Continuity of Operations Plan (Jun'09)
Family Support Services of N. Florida (2013-2014)
Kids First of Florida (2011-2012)
Community Prevention Plan
School Schedules
Clay County School Schedules
Duval County School Schedule
Nassau County School Schedule
Schedules for all counties in Florida
Foster Care Re-Design
Foster Care Re-Design 2007-2009
Video recording of Circuit 4 training held 7/22/08. PowerPoint and additional handouts also available. (total running time 1hr, 45 min)
A Plan for a Radical Change in the FC System
PowerPoint presentation on the FC Redesign project from DCF and FSSNF
Additional Staff Resources and Information
Hearing Your Voice - A Guide to Your Dependency Court Case
Publication from the American Bar Assoc and Florida's Children First. A Guidebook for youth in the Dependency Court system.
Supervisor's Survival Guide (March 07)
From DCF North East Zone Human Resources