Thank you, Liz, so much for your very thoughtful response. I didn't include all the information in my original post, and will answer what I can. It helps me to keep things framed, to be sure. 

Here goes, and this is just off the top of my head.
(1) How old is the baby?  We know it is something over 4.5 months, but how
old NOW?  **Baby is 5 days shy of 6 months old now
(2) How often is the baby feeding, and what are the pees and poops like? Feeding 6-8 times daily (sometimes more, sometimes less), 5-6 wets daily, yellow-tan poop every 1-2 days (all per mother's report). I've encouraged more frequent BF on demand.
 Up until your first first, this was an exclusively BF baby, right? **Yes, mom reports exclusive BF until 3 weeks ago; she stated that her baby's MD told her to supplement formula or food at the 5 month visit.
(3) How much did the baby transfer during the subsequent visits? **Second visit, she said she had fed the baby just before I arrived, and requested "just a quick weight check" as she had to leave shortly to get her son from the bus (I had scheduled with her at the time she'd requested but ended up only spending about 15 minutes there because she needed to leave). I didn't do another test weight yesterday, just a naked weight. 
(4) If this baby is under 6 months of age, and weighs 11.1, how much do you
think the baby *should* have transferred at visit 1?  3 ounces (95 cc) at a
feeding seems just about right to me -- assuming there are frequent enough
feeds throughout the day.  **I agree, I think the amount transferred at that feeding was appropriate and informed her so. But if she transferred that much at each feed, wouldn't the weight be not such an issue? I've been taught that test weights are just a moment in time, and not necessarily predictive/diagnostic. 
(5) Have you discussed pacifier and swaddling as
feeding-opportunity-reducers?  The swaddling part is what concerns me for a
baby who is at least 4.5 months old, and should be engaging with the
outside world with hands and arms and toes and feet. **I have discussed feeding opportunities and meeting sucking needs at breast with her at our first meeting but didn't specifically address the swaddle in a developmental sense.
(6) Any solids yet (again, not knowing baby's age ...) **She offered avocado once, per her report, with little interest from baby. We've discussed age appropriate soft solids to supplement feedings but as of yesterday, mom hadn't tried more solids.
(7) What guidance have you offered her to boost her own supply? **She had received a pump from WIC early on, but reported that her dog ate the flanges and she has not done any pumping in "a couple of months." I talked with her about pumping/hand expression between feeds as a means of increasing supply. She has not contacted her WIC counselor to obtain pump parts, or returned to WIC. I offered information about herbal galactogogues, which she declined.
(8) What in her history suggests IGT; how does your care plan or referrals
address that?  **Breasts widely spaced (about 4"), medial hypoplasia bilaterally, though they are symmetrical. I detailed this in a letter to her doc (family MD, also the baby's provider) and encouraged her to follow up with him.  She declined teaching regarding at-breast supplementation, stating she had tried this with her second baby and didn't like it. I discussed IGT in general with her, making sure that she was aware of the range of possibilities in terms of milk supply, and that good breastfeeding management would optimize supply. 
(9) What breast changes occurred in pregnancy or in immediate post-partum
period? **She reports slight size increase during pregnancy. Reports feeling milk "coming in" upon hospital discharge, and felt a fullness sensation in early weeks. She showed me her breasts but did not permit touching, so I have not palpated. 
(10) LT and TT on baby? What referrals and follow up there? **I am not feeling especially skilled in this area of assessment as far as grading and subtleties. However, tongue cannot extend over lower lip, and thrusts with sucking on my gloved finger. Can lateralize, but did not touch roof of mouth (came near). Lip frenulum visibly attached to gum about midway. She has contacted a pediatric dentist to discuss her concerns; I encouraged her to discuss also with her family doctor to obtain a referral to facilitate insurance concerns, etc.  
(11) Did you teach how to offer the formula supplement in a baby-led way,
and observe that she knows how to do it? I gave her instructions about bottle feeding the breastfed baby in a baby led way, briefly reinforcing them yesterday when I observed a bottle feed.  
(12) Did you or the pediatrician suggest a 10-12 ounces supplement every
day, right off the bat? *I based my suggestion on 2.5oz per lb per day, using the test weight from initial assessment as a guide (assuming 6 feeds at about 3 oz transfer each...which is obviously a guess). Baby weighed 10lb 5 oz at that meeting. 
(13) I known you plan a call to the MD next Monday/business day ... but
have you picked up the phone *before* this? (The penultimate ethical
obligation of the IBCLC is to share health care concerns with the primary
HCP.) **I have given him written reports of all visits, and my assessments, but have not phoned. 
(14) It sounds like this mom has access to WIC services -- do you know if
she has barriers obtaining them (like, I am thinking, traveling to the
office, in your remote location, with three kids in arms, is problematic). *She has used WIC services last in February, seeing her peer counselor. She has not obtained formula there  or had any WIC visits in the meantime. She does have barriers. Our county has offered Maternal/Infant support services, including home visits and help with transport. She has declined enrolling with Maternal/Infant support. The WIC/health department office is about 8 miles from her home.
(15) Have you discussed with the mother how to recognize "baby states" and
behaviors for what they are ... or perhaps shared Jane Heinig's webiste or
its information: http://www.secretsofbabybehavior.com/  *I have not, but thank you for the website. I will share it with her
(16) Did her other kids BF?  What was their weight gain history; how did
those BFg relationships go? *Did not breastfeed first, EBF second for "a while" with reported pain and moved to supplementing then exclusive formula feeding for #2. 
(17) Is Mom being encouraged simply to BF *more?*  Again -- a third baby in
a few years means there are LOTS reasons feedings might be delayed or cut
short. *I have encouraged her to breastfeed more frequently and given her the rationale. I agree, she has lots of things going on at home. 
(18) How's about offering the supplements *between* feeds, rather than
right after?  Maybe this baby isn't "hungry for more" before it is being
offered right after a feeding session -- 95 cc seems like  *I didn't consider this as an option. I will suggest it.
(19) What about this baby's health? Any issues you know of?  I'm thinking
reflux-type stuff that might cause the baby to limit feeds.  *No health issues with baby were reported when I asked mom. 
(20) Has the baby been in to see the pediatrician since you began your
involvement?  What did the doc say to the mom about baby's profess? *No MD visit since I've started working with them.  She has one planned the 22nd of this month. 
(21) Who does mom have available at home either to help with the baby, help
with the other kids, or help with the household chores? *She reports that she's pretty much on her own with this. Her partner works full time, she has a neighbor that she calls a friend, and her mother is about 30 minutes away with transportation challenges. I've strongly urged her to access the Maternal/Infant support services available to her (as has her WIC peer counselor), but she has to consent to them to obtain them. 
(22) How have you adjusted the original care plan given to this mother; did
you take into account her BFg goals and wishes, and ability to follow
through?  *Her goal is to EBF. I have discussed with her that baby may become stronger at breast with growth, that assessment/revision of any TT/LT may help with better breast drainage, adding pumping/hand expression, etc. It seems that she has multiple limitations in terms of follow through, as she has not taken actions to increase supply since we discussed a plan together.  She has contacted a provider to assess and possibly treat for TT/LT. 

You are right, I do feel that a CPS referral isn't strictly indicated here in terms of acute neglect/abuse, and I do have concerns about the ramifications to the family if a referral is made. I hope to gain more insight after conversing with the family doctor.  I do not think she's neglecting the baby or other children. But I do think she needs more support in an ongoing fashion.  I can't make her actually do any of the stuff that I'm urging her to do, and I'm just not sure what else to do!  

Thank you again for your thoughtful and detailed response. 

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