Youth & Family Services Program (CINS/FINS) Eligibility Guide

Please Note:
  • A youth may be given our number and may self-refer, the number may be given to a guardian who may call directly, or a cooperating agency staff may fill out this form and fax it to our office.
  • The youth can not have an open DCF/Eckerd case, or be on probation with DJJ.
  • The guardian will be contacted by us to offer services.
  • To qualify for non-residential counseling services, the child must be between 6-17 years old, and not be under DCF/Eckerd supervision for dependency (i.e. foster care) or for delinquency (i.e. have any assigned community service officer).
  • There cannot be a current DCF/Eckerd investigation for abuse, neglect or abandonment.
  • Youth and Family Services only services Hillsborough County.

Other comments: Any youth between the ages of 10 – 17 may go Hillsborough County Children’s Services for their short-term residential respite program, 3110 Clay Mangum Lane (813) 264-3807 Ext. 53159 or (813) 272-6606, 24 hours a day.

Required fields marked with: *

Referral Source Information

Date of Contact *

Referred by *

Referring Agency (if applicable)


Referral Phone *


Referral Fax Number

Referral Source Email

Youth's Information

First Name *

Last Name *




Date of Birth *
Year:   Month:  
<March 2023>
Birth date selected:  

Name(s) of Parent/Legal Guardian(s)

Email Address

Home Phone *


Work Phone


Cell Phone


Street Address




Referral Source Information

Select all that apply:
School Failure, or frequent truancy, or suspension/expulsion, or learning disabilities.
Additional Notes:

Family parenting issues: or family history of abuse or reglect (prior DCF involvement); or family member (parent, guardian, or sibling) with prior or current criminal history.
Additional Notes:

Current use of alcohol, tobacco, or drugs, or charged with a drug related offense.
Additional Notes:

Behavior problems, including stealing; or running away from home; or association with negative peers; or that have a delinquency record.
Additional Notes:

Services Requested

Select all that apply:

If you would like a copy of this referral sent to you via email, please enter your email address below. If not, you may leave this field blank.

Email Address


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