DFCS Online Policies & Procedures

  DFCS Online Policies & Procedures

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Handbook 4:  Case Plans and Case Management Services
4-11 Intensive Targeted Wraparound Services (ITWS)
Case Plans and Case Management Services
4-11 Intensive Targeted Wraparound Services
Reference Points
Goals of Matrix
Who Is Served
What Services Are Provided
Referral Steps
Community Agency Providers
Service Provider Professional Teams
Termination of ITW Services
ITWS Payments regarding Youth on Runaway Status
Other References

Reference Points
Effective Date: 7/1/07
Last Updated: 5/30/2014
 Legal Basis:
Popup Window California Senate Bill (SB) 163
 Non CWS/CMS Forms:
MS Word RISC Referral (SCZ63-WRAP)
 CWS/CMS Forms:
PDF Forms Text


Intensive Targeted Wraparound Services (ITWS) is a community-based alternative program to provide youth at risk of being placed in a group home or other institutional environment with individualized support and services designed to allow them to function at home and in their communities. Youth eligible to receive Intensive Targeted Wraparound services include Juvenile Court dependents that have significant behavioral and emotional needs. These youth are at high risk for placement failure due to the nature and severity of their special needs.  The Intensive Targeted Wraparound Program is designed to meet the unique individual needs of youth and their families through the syntheses of Wraparound, Family Finding, Intensive Therapeutic Foster Homes (Professional Parents) and evidenced based mental health services. 

The mission of the program is to provide the highest quality, ethically based, and culturally proficient services in a strength-based, needs driven and individualized manner for each youth and their family and/or caregivers.
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Goals of ITWS  

The overall goal of ITWS is to ensure that youth are able to remain safe and productive in the community.  The program seeks to achieve this goal by helping youth develop:

  • Increased educational achievement
  • Increased vocational preparedness
  • Increased family connectedness
  • Increase placement stability and permanency


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Who Is Served  

ITWS serves the high-risk dependency population who exhibit severe behaviors resulting in placement instability.  The program serves both male and female child/youth who:

  • Are between the ages of 10-21
  • Are dependents of the Juvenile Court
  • Meet the criteria for placement into an RCL 13/14

 A child or youth who is referred for 12/13/14 Wraparound services must:

  • Have a mental disorder as identified in the most recent edition of the Diagnostic and Statistical Manual (DSM) of Mental Disorders, other than a primary substance use disorder or developmental disorder, which results in behavior inappropriate to the child's age, and
  • Meet one or more of the following criteria:
    1. As a result of the mental disorder the child has substantial impairment in at least two of the following areas:
      • Self care
      • School functioning
      • Family relationships
      • Ability to function in the community

    And either of the following occurs:

      • The child/youth is at risk of removal from home or has already been removed from home.
      • The mental disorder and impairments have been present for more than six months or are likely to continue for more than one year without treatment.

    2. The child/youth displays one of the following:

      • Psychotic features
      • Risk of suicide
      • Risk of violence due to a mental disorder
      • Child/youth who exhibit one or more of the following, but not limited to:
      • Frequent running away
      • Gang involvement
      • Suicidal Risk
      • Juvenile Sexual Perpetrator
      • Commercially Sexually Exploited Child (CSEC)
      • Sexualized behavior
      • Substance abuse
      • Posttraumatic stress disorder
      • Fire starter
      • Aggressive/assaultive behavior
      • Multiple placements
      • Youth criminal behavior beyond control   

        of parents and/or primary caretakers

      • Oppositional/defiant behavior
      • School behavior/truancy problems
      • Self-injurious behavior
      • Dually involved youth  

                (DFCS/JPD, JPD/MHD, DFCS/MHD)

      • One or more psychiatric hospitalizations
      • Repeated episodes of placement  

                 disruptions, high vulnerability to  

                 homelessness and transience, and/or at         

                 risk of life threatening behaviors.  


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What Services Are Provided  

ITWS services are provided 24 hours a day/7 days a week, which include:

  • The process for individualized safety planning and case management of Intensive Targeted Wraparound services includes:
  • Conducting a comprehensive, strength-based assessment of each child and family member.
  • Developing individualized child and family service plans as an adjunct to the DFCS case plan that identifies needed services and incorporates a transition plan.
  • Resource identification, coordination, and access.
  • Configuring Child and Family Teams to include language and culture
    • Identify staff to meet cultural and language needs of the family.
  • Provision of direct home-based and community-based services and supports, which includes assisting the family and child with:
    • Basic needs
    • Social environment
    • Family environment
    • School/vocational success
    • System involvement
    • Mental health needs
    • Legal referrals
    • Crisis management
    • Respite care
      • The agency providers are responsible for having options for respite care, including having the adults cleared thorough LiveScan fingerprinting.
  • Monitoring services.
  • Interagency service coordination.
  • Supervision and monitoring of community participation.
  • Parent coaching and support.
  • Planning for discharge or graduation from services.

ITWS provider agencies:

  • Utilize a trauma informed model such as Trauma Focused Cognitive Behavioral Therapy for delivery of mental health services.
  • Make available highly trained Intensive Therapeutic Foster Parents.
  • Provide Family Finding services, which include family connectedness maps, web-based searches, and family engagement.
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Referral Steps  





  • Schedules a TDM to discuss the child's/youth's placement options.
  • Consults with the DFCS RISC Coordinator, (408-501-6813).

Social Worker


  • Reviews the RISC referral (SCZ63-Wrap).

RISC Coordinator


  • Assign ITWS provider.

RISC Committee Members


  • Submits recommendations (RECS 150-161) to the court for Wraparound services at the next Hearing or on an Application for Order.
  • Participates in Child/Family Team meetings a minimum of once a month during the course of services to the child/youth and/or family.

Social Worker

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Community Agency Providers  
  • Two community based organizations provide ITWS in Santa Clara County. 

    •  EMQFF: Matrix
    • Seneca Family of Agencies: Seneca PLUS (Positive, Lasting, Unconditional Services).  
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Service Provider Professional Teams  

The team of professionals who support the child/youth and the family as part of Intensive Wraparound services consists of a:

  • Clinical Program Manager (CPM)
    • The CPM conducts orientation meetings, provides oversight of the services and handles customer service needs.
  • A Facilitator
    • The facilitator leads each Child Family Team Meeting, facilitates the development of Treatment Plans and Individualized Child Family Plans and initiates the Family Finding process when needed.
  • Family Specialist
    • Family Specialists are responsible for all the direct work with the child on each team, and they provide intensive in-home and community based services. 
  • Program Supervisor
    • The Program Supervisor oversees the Family Specialists to ensure fidelity to the wraparound process.
  • Family Partner
    • The Family Partner provides support specifically to the parents or caretakers.
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Time line for ITW service delivery  



Time line


RISC assigns the referral for ITW services.

RISC Meeting


The provider receives the referral.

Same day of the RISC Meeting


The facilitator contacts the family.

Within 4 days of the assignment of the referral to a provider


An initial face-to-face meeting between the family and the services provider occurs.

Within 5 days of the assignment of the referral to a provider or at the family's earliest convenience


The first family team meeting occurs.

Within 2 weeks of the assignment of the referral to a provider


The safety plan and individualized child and family plan are developed.

Within 60 days of the assignment of the referral to a provider and at 6 month intervals thereafter.


The mental health assessment and treatment plans are completed and implemented

Within 60 days of the initial face-to-face contact


The Quarterly Report regarding the development and implementation of the individualized child and family plan is completed and submitted

Within 90 days of the assignment of the referral to a provider


The discharge plan is developed and presented to the Community Oversight Committee.

Prior to graduation from the Wraparound program

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Termination of ITW services  

Graduation and transition out of ITWS occurs when thechild/youth and family have achieved the goals developed in collaboration with the referring agency at the beginning of services.  Planning for discharge or graduation from the program starts upon the initiation of service delivery.  The plan is presented at community oversight meetings, prior to a child/youth leaving services.  The plan includes aftercare and appropriate community-based services to support the family.  In the event of a child/youth and family withdraw from services or leave services prematurely, a discharge summary is presented at a community oversight meeting. 

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ITWS Payments regarding Youth on Runaway Status  
  • Youth is on Runaway Status Two (2) Days or Less

If the child/youth on runaway is absent for two days or less, the social worker has the discretion to enter into an agreement with the service provider to keep the Wraparound services open for the youth with no interruption in funding.

  • Youth on Runaway Status Three (3) Days or More

    If the child/youth on runaway status is absent for three days or more, the social worker must have the social work supervisor and the SSPM approve the continued payment.

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Other References  
bullet2 OPP Chapter 13-8: Team Decision Making (TDM)
bullet2 OPP Chapter 19-6:  How to Refer a Child to RISC (Resource and Intensive Services Committee)
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