6-13-03 - Wisconsin DCF
DEPARTMENT OF CHILDREN AND FAMILIESDivision of Safety and PermanenceChild Description for Foster Home Placement RecruitmentUse of form: Use of this form is a requirement to request a Foster Home recruitment through the Bureau of Regional Operations for children placed in out-of-home care and a foster home resource is needed for the child. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].Instructions: Complete all sections belowToday’s Date FORMTEXT ?????Date Placement Needed FORMTEXT ?????Special Considerations FORMCHECKBOX Sibling Placement Needed FORMCHECKBOX Short-Term Placement Only FORMCHECKBOX Anticipated Long-Term PlacementName – Child (First Name Only) FORMTEXT ?????Gender FORMCHECKBOX Male FORMCHECKBOX FemaleAge (years/months) FORMTEXT ?????Race (Check all that apply) FORMCHECKBOX African American FORMCHECKBOX Asian FORMCHECKBOX Hispanic FORMCHECKBOX Native American FORMCHECKBOX Pacific Islander FORMCHECKBOX WhiteEthnicity FORMTEXT ?????ICWA Status FORMCHECKBOX Yes FORMCHECKBOX NoIndian Tribe FORMTEXT ?????Date of Removal FORMTEXT ?????Reason(s) for Removal (Check all that apply) FORMCHECKBOX Physical Abuse FORMCHECKBOX Sexual Abuse FORMCHECKBOX Emotional Damage/Abuse FORMCHECKBOX Neglect FORMCHECKBOX Unborn Child Abuse FORMCHECKBOX Delinquency FORMCHECKBOX Developmental Disability FORMCHECKBOX AODA FORMCHECKBOX Physical Handicap FORMCHECKBOX Behavioral Issues FORMCHECKBOX Emotional Disturbance FORMCHECKBOX OtherLegal Status FORMDROPDOWN County of Jurisdiction FORMTEXT ?????Current Placement Setting FORMDROPDOWN Permanency Goal(s) FORMTEXT ?????Number of siblings to be placed together FORMTEXT ?????Names and Ages – Siblings (First Names Only) FORMTEXT ?????A.Child Specific InformationStrengths (What does the child do well?): FORMTEXT ?????Interests/Hobbies: FORMTEXT ?????Likes/Dislikes: FORMTEXT ?????Family Interaction frequency and location: FORMTEXT ?????Sibling relationships and frequency of sibling contact: FORMTEXT ?????Important connections to maintain for the child: FORMTEXT ?????Physical Health and Medical Strengths and Needs: FORMTEXT ?????Behavioral Health Strengths and Needs: FORMTEXT ?????Educational Strengths and Needs: FORMTEXT ?????Family characteristics to meet child’s needs: FORMTEXT ?????Immediate needs of the child: FORMTEXT ?????rmation for Workers OnlyLevel of Need (Child) FORMTEXT ?????Medications FORMTEXT ?????Diagnoses FORMTEXT ?????Types of Services Provided – Child FORMTEXT ?????Provider Characteristics (Check all that Apply) FORMCHECKBOX ADD/ADHD requiring medication FORMCHECKBOX AIDS Infection or HIV Positive FORMCHECKBOX AODA FORMCHECKBOX Adoption Only FORMCHECKBOX At least one parent stays home FORMCHECKBOX Attachment FORMCHECKBOX Autism FORMCHECKBOX Behavioral difficulties in school FORMCHECKBOX Bilingual capacity FORMCHECKBOX Chronic school issues FORMCHECKBOX Cognitive delays FORMCHECKBOX Communicable diseases FORMCHECKBOX Concurrent FORMCHECKBOX Crisis respite FORMCHECKBOX Cruelty to animals FORMCHECKBOX Delinquency history FORMCHECKBOX Depression FORMCHECKBOX Developmental delays FORMCHECKBOX Drug affected infant FORMCHECKBOX Emergency placements FORMCHECKBOX Emotionally abused FORMCHECKBOX Enuresis/Encopresis FORMCHECKBOX Fire setting FORMCHECKBOX Food/Eating issues FORMCHECKBOX Gang involved FORMCHECKBOX History of making false allegations FORMCHECKBOX History of running away FORMCHECKBOX Hyperactivity FORMCHECKBOX Infant FORMCHECKBOX LGBTQ FORMCHECKBOX Legal risk FORMCHECKBOX Limited life expectancy FORMCHECKBOX Medically needy/fragile/complex FORMCHECKBOX Mental health issues FORMCHECKBOX Neglected FORMCHECKBOX Personal care needs FORMCHECKBOX Physically abused FORMCHECKBOX Physically aggressive FORMCHECKBOX Pregnant/parenting FORMCHECKBOX Previous foster family contact post-adoption FORMCHECKBOX Psychiatric hospitalization history FORMCHECKBOX Psychotic FORMCHECKBOX Requires oxygen FORMCHECKBOX Requires Smoke and pet dander free home FORMCHECKBOX Requires special diet FORMCHECKBOX Ritually abused FORMCHECKBOX Self-injurious FORMCHECKBOX Severe respiratory problems FORMCHECKBOX Sexual behaviors FORMCHECKBOX Sexually abused FORMCHECKBOX Sibling group FORMCHECKBOX Significant asthma or allergies FORMCHECKBOX Significant hearing loss or is deaf FORMCHECKBOX Significant impaired vision or blind FORMCHECKBOX Sleeping issues FORMCHECKBOX Suicidal/Homicidal FORMCHECKBOX Supervised family interaction FORMCHECKBOX Teens FORMCHECKBOX Transports long distance FORMCHECKBOX Wheelchair accessible FORMCHECKBOX Witness to violence community or family FORMCHECKBOX Works closely with birth parentsC.Contact InformationWorker Name FORMTEXT ?????Agency Name FORMTEXT ?????Email Address FORMTEXT ?????Telephone Number FORMTEXT ????? ................
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