Form Fsp 1 - Family Stabilization Program Evaluation Request
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FAMILY STABILIZATION PROGRAM EVALUATION REQUEST
CalWORKs can help you if you or your family members are facing a crisis or situation that is preventing you from
being able to participate in Welfare-to-Work. You can ask the County Welfare Department to help you with your crisis
or situation.
INSTRUCTIONS: All information must be completed. Both the Welfare-to-Work case worker and Welfare-to-Work participant
must sign the form. A copy is given to the Welfare-to-Work participant, and a copy is kept in the
participant’s case file.
CASE NAME
CASE NUMBER
WELFARE TO WORK PARTICIPANT
PHONE NUMBER
WORKER PHONE NUMBER
WORKER NUMBER
CASE WORKER (CONTACT PERSON)
I am requesting an evaluation for Family Stabilization services.
The crisis or situation that I need help with is:
DATE
WELFARE-TO-WORK PARTICIPANT SIGNATURE
DATE
CASE WORKER SIGNATURE
FSP 1 (8/14) REQUIRED FORM - SUBSTITUTES PERMITTED
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