CREATING THE HEALTH & EDUCATION PASSPORT



Health & Education Passport

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Central CA Training Academy

559-278-5757

Terry Luna, CWS/CMS Project Coordinator

terril@csufresno.edu

Table of Contents

Legislative Cites for Health & Education Passport Page 2/3

Creating the Health & Education Passport Page 4

Client Notebook Page 5

Recording Education Information Page 6

Deleting an Education Notebook Page 7

Using the Health Notebook Page 8

Recording Psychotropic Medications Page 9/10

Recording Well Child Exams – Contact Notebook Page 11

Service Provider Search Tips Page 12

Placement Information Page 13

Health/Education Related Outcome Measures:

Timely Medical & Dental Exams – 5B(1) & (2) Page 14

Psychotropic Medications – 5F Page 15

Individualized Education Plans – 6B Page 16

Forms:

Passport Mapping Page 17/25

CALIFORNIA WELFARE AND INSTITUTIONS CODE

Division 9. PUBLIC SOCIAL SERVICES

Part 4. SERVICES FOR THE CARE OF CHILDREN

Chapter 1. FOSTER CARE PLACEMENT

§ 16010.

a) When a child is placed in foster care, the case plan for

each child recommended pursuant to Section 358.1 shall include a

summary of the health and education information or records, including mental health information or records, of the child. The summary may be maintained in the form of a health and education passport, or a comparable format designed by the child protective agency. The health and education summary shall include, but not be limited to, the names and addresses of the child's health, dental, and education providers, the child's grade level performance, the child's school record, assurances that the child's placement in foster care takes into account proximity to the school in which the child is enrolled at the time of placement, the number of school transfers the child has already experienced, the child's educational progress, as demonstrated by factors, including, but not limited to, academic proficiency scores, credits earned toward graduation, a record of the child's immunizations and allergies, the child's known medical problems, the child's current medications, past health problems and hospitalizations, a record of the child's relevant mental health

history, the child's known mental health condition and medications, and any other relevant mental health, dental, health, and education information concerning the child determined to be appropriate by the Director of Social Services. If any other law imposes more stringent information requirements, then that section shall prevail.

DIVISION 31 REQUIREMENTS (31-200 & 400)

31-206.35

For children receiving out-of-home care, the social worker shall document in the case plan, the following:

Health and Education Information about the Child:

✓ Names and Addresses of the child’s health and education providers.

✓ Child’s grade level performance.

✓ Child’s school record.

✓ Assurances that the child’s placement in foster care takes into account proximity to the school in which the child is enrolled at the time of placement.

✓ A record of the child’s immunizations.

✓ The child’s known medical problems.

✓ The child’s medications.

If any of the required health and education information is not contained in the case plan, the case plan shall document where the information is located.

31-206.361

Each child in placement shall receive a medical and dental examination, preferably prior to, but not later than, 30 calendar days after placement.

31-405.1

(m)

Ensure that information regarding available CHDP services is provided to the out of home care provider within 30 days of the date of the placement.

(n)

Ensure that the child receives medical and dental care which places attention on preventive health services through the Child Health and Disability Prevention (CHDP) program, or equivalent preventive health services in accordance with the CHDP program’s schedule for periodic health assessment.

1) Each child in placement shall receive a medical and dental examination, preferably prior to, but not later than, 30 calendar days after placement.

(o)

Make certain that arrangements for, and monitoring of, the child’s educational progress while in placement are undertaken.

(s)

Provide the out-of-home care provider the child’s background information as available, including, but not limited to, the following histories:

✓ Educational

✓ Medical

✓ Placement

✓ Family

✓ Behavioral

(q)

Provide the out-of-home care provider(s) information of any known or suspected dangerous behavior of the child being placed.

CREATING THE HEALTH & EDUCATION PASSPORT

The Health & Education Passport is populated from several Notebooks throughout CWS/CMS. Information cannot be entered directly onto the Passport.

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Client Notebook – several pages of this notebook populate the passport with basic child information. The ‘service provider’ page will populate past and present health service providers of the child.

Education Notebook – this notebook populates the passport with past and present educational information for the child.

Health Notebook – this notebook populates the passport with all relevant health history for a child, including ‘diagnosed conditions’, ‘medications’, ‘hospitalizations’, ‘immunizations’, etc.

Contact Notebook – The Associated Services page of the contact notebook must be used to document CHDP – Physical & Dental information. Only Well Child exams with an HEP indicator will populate to the passport.

Placement Notebook – Use the ID page of this notebook to document the ‘date SCP informed of the CHDP program and that brochure was given’; if ‘SCP requests CHDP services’; and ‘date SCP was given the HEP and informed of it’s purpose’.

Use the ID page to note that Social Worker considered proximity to the school in which the child was enrolled at time of placement.

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Use the ‘Create New Document-Client’ Notebook to generate the Passport.

Select the Time Frame parameters from the next dialog box.

This will create the Passport in Microsoft Word. It can be Saved and Printed, but CANNOT be edited! Any changes must be made in the Notebooks, then the passport can be removed – and re-created. There can only be ONE passport per child. The passport can be continually refreshed, by removing it and recreating it.

SAVE TO DATABASE

CLIENT NOTEBOOK

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Areas in GREEN are important to complete for Passport.

[pic] Enter basic identifying client information here, DOB, SS, ethnicity and language. If child is in placement, be sure to check the confidentiality in effect box.

[pic] Enter basic demographic information for the client, birthplace, arrests, etc.

[pic] Record all address changes here. Be sure to enter start and end dates for addresses.

NOTE: this is NOT the place to change an address for a child in placement or when a foster parent or relative caregiver moves.

[pic] Enter any other names or AKA’s that your client may use. This will cross-reference all names when a client search is done.

[pic] Relate all clients to each other on this page. Be sure that the relationship is in the correct order as they are listed or they will populate incorrectly to many documents that CWS/CMS produces.

[pic] This page is where the county case number is entered. It is important that the number be active (no end date), if this is a child that a placement will be recorded for. Other types of numbers can be entered here for clients, for example, CII, MEDS Id, etc.

[pic] Juvenile court numbers are entered on this page for children only.

[pic] Parent search information is recorded on this page. Record searches information in the parent’s notebook. Search results entered here will populate to the Declaration of Due Diligence.

[pic] Eligibility information to Foster Care is recorded on this page.

[pic] Once an attorney has been appointed on behalf of a client, they must be attached on this page.

[pic] Use this page to show service providers involved with client. Use the plus + sign to add service provider. Service providers with no END date – will populate Current Service Provider section of passport. Providers with END date entered populate the ‘past provider’ section. Only Providers that have been used in a Contact will appear under the plus. Use the Search option to located Providers that are not in the list.

[pic] This page records information about a child’s Indian status – it must be completed before ICWA notices can be generated from CWS/CMS.

QUICK GUIDE TO THE EDUCATION NOTEBOOK

There should only be ONE notebook per school the child has attended.

|Record the school child is attending: |SEARCH TIPS: |

| | |

|Before you can record education information for a child, you must SEARCH for |You must select ‘School Category’ and at least one other identifying |

|the school that the child is attending. |factor. The easiest method is to choose your county, the under the |

| |‘school’ drop down, all schools in your county will appear – then |

| |select the one you want from the list. |

|Create New Education |After using the plus button – to Create New Education notebook for a |

| |child: |

|[pic] [pic] |Highlight the child’s name you want to place in school, then highlight|

| |the school child is attending. Click OK. |

| |Use this page to record the date the child began attending this |

|[pic] |school. |

| | |

|[pic] |Use this page to record child’s grade level and attendance records, |

| |progress, report cards, IEP, associated with that grade level. |

| |Always use the plus button (+) to add history for each grade level. |

| |SAVE TO DATABASE |

|Once the child has been recorded as attending school, additional information gathered at each contact can be recorded in the child’s ‘Existing |

|Education Notebook’. |

| | |

|[pic] [pic] |Open the child’s existing education notebook in order to add |

| |additional education information. |

| | |

|[pic] |Use the appropriate page to record the information you have gathered. |

| | |

|[pic] | |

| | |

| |SAVE TO DATABASE |

| | |

|Remove a child from school: |Open the child’s existing education notebook, and record the end date |

| |and reason child is no longer attending this school. |

|[pic] [pic] [pic] | |

| |SAVE TO DATABASE |

Deleting an Education Notebook (if entered by mistake)

Open the Education Notebook that you want to remove – and go to the Education Record Page.

Remove all rows from the page – highlight row, and use the delete key.

All rows must be deleted from this page.

Then open ‘Existing Education Notebook’:

The remove button should be available.

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HEALTH NOTEBOOK

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[pic] Use this page to summarize a child’s current condition. When a new Summary is entered, the old Summary is erased. It will only remain on a hard copy of the previous HEP. This Summary does NOT keep history. Has the child been clinically diagnosed by a qualified professional as having at least one of the following disabilities: mental retardation; visually or hearing impaired; physically disabled; emotionally disturbed, or other medically diagnosed conditions requiring special care.

[pic] Use this page to record any conditions a child has which are diagnosed by a practitioner or a clinic. Record as much information about the condition as possible. Use start and end dates to document child’s health history. If an alert is checked, the condition will populate to first page of Passport.

[pic] Use this page to record any conditions a child may have that have been observed by someone. Record as much information about the condition as possible. Use start and end dates to document child’s health history. Observed conditions will only print to passport if the alert is checked.

[pic] Use this page to document any medications prescribed for a child. Each medication must be tied to a ‘Client Condition’ (which comes from the ‘Diagnosed Conditions’ page.)

Hospitalizations Use this page to document anytime a child has been hospitalized. The hospitalization must be tied to a ‘Client Condition’.

Medical Tests Use this page to document any medical tests ordered for a child and those test results. The medical tests must be associated with a ‘Client Condition’.

Referrals Use this page to document any medical referrals made on behalf of a child by a Health Provider. The referrals must be associated with a ‘Client Condition’.

[pic] Use this page to document a child’s immunization history.

Well Child Use this page to record information regarding a child’s Well Child exam. You must enter a Well Child Exam as an Associated Service in the Contact Notebook PRIOR to completion of the information on this page.

Birth History Use this page to enter birth history information for a child. This is also a good place to record a toxicology screening. Certain information on this page is duplicated on the Demographic page of the client notebook. The information will cross populate each notebook.

SAVE TO DATABASE

RECORDING PSYCHOTROPIC MEDICATIONS IN THE HEALTH NOTEBOOK Outcome Measure 5F

Open the child’s Health Notebook and use the Diagnosed Conditions & Medications Pages:

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DIAGNOSED CONDITION Page:

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✓ Onset Date:

Date condition was diagnosed by practitioner. This could be before or after child entered foster care.

✓ Condition – Health Problem:

Choose the most appropriate health problem, avoid using Psychotropic Medication required.

✓ Health Problem Description:

Add the condition as written on the JV220.

MEDICATIONS Page:

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One medication per line:

✓ Prescribed Medication is attached to the diagnosed condition it has been prescribed for.

✓ Prescribed By: enter the doctor that prescribed the medication.

✓ Start date – with NO end date indicates current medication. Use the actual date child begins taking the medication.

✓ Projected End Date: Date the court order expires (should be 6 months/180 days from date of current court order).

✓ End Date: Only use this to record a medication that the child is no longer taking.

✓ Court Ordered Date: Date the JV220 is signed by the judge. Update this date as new court order is signed for current medication – add a new row with new date.

✓ Comment/Instructions:

o Date each entry

o List the dosage or range

o List alternative medications listed on the JV220 that may be given in the future

o If medication is same, but new doctor – note here and Prescribed By field.

✓ Check appropriate radio buttons if the medication is ‘psychotropic’ and if administered for ‘psychiatric purposes’.

✓ An ‘automatic reminder’ will be generated from the court order date or if no date has been entered.

QUICK GUIDE TO RECORDING CONTACTS & SERVICES

|Create New Contact: |Use the Contact Notebook to record every contact (narrative) that is |

| |made on behalf of a child. If more than one child is selected – then |

| |that narrative will go to all selected children’s cases. |

|[pic] [pic] [pic] |Be sure to complete all YELLOW fields. |

| | |

| |Use the ‘Spell Check’ command under the Edit menu once narrative has |

| |been entered. |

| | |

| |If Social Worker provided any type of a case management service for |

| |child or family, be sure to select service type under ‘Case Management|

|RECORD A CASE MANAGEMENT SERVICE WITHIN THIS CONTACT: |Service Type’. |

| |This will complete the Associated Services page, and Social Worker can|

| |add narrative entry to this page. |

|RECORD SERVICES BEING PROVIDED ON BEHALF OF A CHILD/FAMILY: |Open ANY existing contact or complete a NEW contact, then click on the|

| |Associated Services page. |

|[pic] [pic] [pic] | |

| |Use the plus button in the upper left corner to add each Service |

| |provided to child/family. |

| | |

| |Be sure to complete all YELLOW fields. |

| | |

| |If you are unable to find the Service Provider in search, go to the |

| |next step: Create New Service Provider. |

| | |

| |The ‘Well Child Exam’ button will become enabled ONLY if the following|

| |services are selected: |

| |HEP – CHDP Equivalent Physical Exam |

| |HEP - CHDP Physical Exam |

| |HEP - Required Dental Exam |

| |A Well Child Exam can be recorded for ONLY one child at a time. |

|CREATE NEW SERVICE PROVIDER: |**Only create a service provider, if you were unable to locate |

| |provider using SEARCH.** |

|[pic] [pic] [pic] , [pic] |Complete both pages with as much information as you can. |

| |Be sure to complete all YELLOW fields. |

SERVICE PROVIDER SEARCH Tips:

Most service providers are already in the database, the trick is finding them.

You can search with provider’s first and last name, or agency name, or any combination. There is no phonetic search – that means that your spelling has to be just right, or you will not find the provider.

You can search using City or Zip Code to narrow the search.

Only the first 50 providers will be displayed in the Search, but there will be a message telling you there are more than 50. You must enter additional search parameters in order to view more.

Use the ‘Wild Card’ for additional search power.

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PLACEMENT NOTEBOOK

Open the Existing Placement:

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[pic] Record the ‘Date the Substitute Care Provider was informed of the CHDP program and the brochure was given.

If the Substitute Care Provider requests CHDP services be provided, check the box indicating so.

Document the Date the Substitute Care Provider was given the Health and Education Passport, and informed of it’s purpose.

Rationale section:

Use this page to document that the child’s placement in foster care takes into account proximity to the school in which the child was enrolled at the time of placement and whether or not the child attends the same school as prior to the placement.

SAVE TO DATABASE

Timely Medical and Dental Exams State Measure – 5B(1) and 5B(2)

This measure provides the percent of children meeting the schedule for CHDP/Division 31 medical and dental exams. Minors must have a medical and/or dental exam by the end of their age period.

CWS/CMS

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Child must be in placement and episode open 31 days or more.

Placement home is in California.

Minor’s age taken at quarter end.

Excludes:

Non-CWD placements (probation, etc)

Placement episodes open less than 31 days

Children in placement homes outside of CA

Runaways

Non-foster care placements

Non dependent Legal Guardians

Contact Notebook:

[pic] [pic] [pic] [pic]

A ‘delivered service’ must be recorded in the contact notebook on the Associated Services page of:

Use these types only:

CHDP Medical Exams CHDP Dental Exams

Health/CHDP Services CHDP Dental Delivered

CHDP Medical Delivered HEP-Periodic Dental Exam

HEP-CHDP Equivalent Physical Exam

HEP-CHDP Physical Exam

|Medical Assessments-Age Exam Categories |Dental Assessments |

|Under 1 month |3 years and once a year thereafter till age 20 |

|1 to 2 months | |

|3 to 4 months | |

|5 to 6 months | |

|7 to 9 months | |

|10 to 12 months | |

|13 to 15 months | |

|16 to 23 months | |

|2 years | |

|3 years | |

|4 to 5 years | |

|6 to 8 years | |

|9 to 12 years | |

|13 to 16 years | |

|17 to 20 years | |

Authorization of Psychotropic Medications State Measure – 5F

This measure provides the percent of children in foster care with a court order or parental consent that authorizes the child to receive psychotropic medication.

CWS/CMS

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ID page: Agency Responsibility is County Welfare Agency

Includes:

✓ Placement Episode Open or Closed during the quarter

✓ Placement open or Closed during the quarter

✓ Outgoing ICPC placements

✓ Runaways or Closed Placement w/Open Episode

Excludes:

✓ All non child welfare agency placements (probation, other)

✓ All placements with Legal Authorization codes other than WIC a-j, e, h, 601 & 602

✓ Incoming ICPC placements

✓ Non-foster care placements

✓ Non Dependent Legal Guardians

✓ Children in Placement Facility Type – Guardian home

[pic] [pic] [pic]

One medication listed on this page must be Active – no end date. Or the medication must have been active during the review period. A Psychotropic Medication consent date must have occurred prior to the last day of the review period – either Court Order or Parental Consent date.

No end

date

Individualized Education Plan (IEP) State Measure – 6B

This measure provides the percentage of children in out-of-home (OHP) placements who have ever had an IEP.

CWS/CMS

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✓ Child must have an open case.

✓ Child must be in placement.

✓ Placement episode must be 31 days or longer.

✓ Child must be placed in California.

Exclude:

✓ Non-dependent legal guardianship placements.

✓ ICPC placements (in or out).

✓ Children younger than 3 years old.

✓ Children who turned 3 years old 31 days or less before the end of the quarter.

✓ Children 19 years of age or older.

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Heath & Education Passport Mapping

The Health & Education Passport is a protected document – it cannot be changed or modified in Microsoft WORD.

Use the Mapping on the following pages to determine the notebooks, pages and fields in CWS/CMS that populate to each section of the Health Passport. Each section is color coded to indicate which section in CWS/CMS each notebook is found.

Once changes have been made in CWS/CMS – Save to Database – then remove the ‘OLD’ Passport and recreate a ‘NEW’ Passport. The Passport will be refreshed with the new information added in the CWS/CMS Screens.

Confidential

Health

and

Education

Passport

Instructions to Foster Parents

Please keep this Health and Education Passport while this child is in your care. Please keep the child’s Medi-Cal card, health eligibility identification cards, Medical Consent form, Birth Certificate and Immunization record with this Passport.

Take this Passport to all medical, dental, and educational visits pertaining to the child. Remind doctors, dentists, and teachers, mental health care providers, vision care providers, and other health care providers to add or correct information on the form after each visit. Please give the corrected Passport to the social worker at your next meeting. When the child leaves your care, the latest update of this Passport will go with the child to aid the next care provider.

If you have any questions, please speak with the child’s social worker and/or Public Health Nurse.

Thank you.

|CHILD INFORMATION |

|CHILD’S NAME |BIRTH DATE |AGE |GENDER |

|Client Notebook – ID Page |Client Notebook – ID |Client Notebook|Client Notebook –|

| |Page |– ID Page |ID Page |

|NAME ALSO KNOWN BY |CHILD ID NUMBER |COURT NUMBER |

|Client Notebook – Names Page |Client Notebook – ID Page |Client Notebook – Juvenile Court Number Page |

|CASE NUMBER |MEDI-CAL RECORD NUMBER |MEDICAL INSURANCE COMPANY NAME / HMO |POLICY NUMBER |

|Case Information notebook-ID page |Client Notebook – ID Num|FC-2 Eligibility Application NB – Insurance Page |FC-2 Eligibility Application NB – |

| |Page (Medical Record) | |Insurance Page |

|ADDRESS |SOCIAL SECURITY NUMBER |

|If Child is in Placement – “Confidential Address” should appear here. |Client notebook-ID page – Will NOT populated even if |

|Client Notebook, ID page – checkmark in “Confidentiality in Effect” |entered |

| |PHONE |

| |Client notebook-Address page |

|ETHNICITY |RELIGION |ICWA ELIGIBILITY |

|Client Notebook – ID Page |Client notebook-Demographics |Client Notebook – ID Page |

| |page | |

|PRIMARY LANGUAGE |SECONDARY LANGUAGE |

|Client Notebook – ID Page |Client Notebook – ID Page |

|NAME OF SUBSTITUTE CARE PROVIDER |RELATIONSHIP TO CHILD OR TYPE OF FACILITY |

|If Child is in Placement – “Confidential Name” will appear here |If Child is in Placement – “Confidential Relationship” will appear here. Client |

| |Notebook, ID page – checkmark in “Confidentiality in Effect” |

|SCHOOL NAME |SCHOOL ADDRESS |GRADE |

|Education Provider-ID page- the school name will populate for the school that |Education Provider-Address page |Education notebook,|

|has a start date – and no end date. | |Grade Level |

| | |Information page |

|PHONE | | |

|Education notebook-Grade Level Information page | | |

|CURRENT HEALTH INFORMATION |

| | |SENSITIVE HEALTH & MEDICAL INFORMATION ON FILE (Health Notebook-Summary page – Sensitive Checkbox) |

| | |LIMITATION PUT ON SUBSTITUTE CARE PROVIDER’S ABILITY TO MAKE HEALTH DECISIONS(Health Notebook-Summary page) |

| | |INDIVIDUAL HEALTH CARE PLAN ON FILE FOR SPECIAL NEEDS CHILD (Health Notebook-Summary page) |

|** ALERTS ** |

|DESCRIPTION | |

| |Health notebook, Diagnosed Condition and Medications pages (Alert box) |

!@#$%(10)

|ALLERGIES |

|DESCRIPTION |Health Notebook-Diagnosed Condition (Allergies) |

| | |

|ONSET DATE/FIRST VISIT |DIAGNOSED BY |

|Health Notebook-Diagnosed Condition |Health Notebook-Diagnosed Condition |

!@#$%(0)

|SUMMARY OF CHILD’S CURRENT HEALTH CONDITION |

|Health notebook, Summary page – Narrative entry from this field populates here. |

|DEVELOPMENTAL / FUNCTIONAL LIMITATIONS |

| |VISUAL IMPAIRMENT | |HEARING IMPAIRMENT | |SPEECH IMPAIRMENT |

| |SPECIAL DIET REQUIRED | |NEUROLOGICAL IMPAIRMENT | |MEDICAL EQUIPMENT REQUIRED |

| |DEVELOPMENTALLY DISABLED | |NON AMBULATORY | |MEDICAL PROCEDURES REQUIRED |

| |DEVELOPMENTALLY DELAYED | |SPECIAL EDUCATION PUPIL, CERTIFIED | |EMOTIONAL DISORDER, DSM, CURNT REV |

| OTHER |DESCRIPTION | |

| | Health notebook-Diagnosed Condition page (choose these under Physical, Behavioral or Emotional category) |

|CURRENT HEALTH ISSUES |

|Each Health Problem without an end date on Diagnosed Conditions Page is followed by related information from the Health notebook-Medications, Hospitalizations, Medical|

|Tests, and Referrals pages. |

|HEALTH PROBLEM |ONSET DATE/FIRST VISIT |NEXT SCHEDULED VISIT DATE |

|Health notebook-Diagnosed Condition page |Health notebook-Diagnosed Condition page |Health notebook-Diagnosed Condition page |

|DIAGNOSED BY: NAME |DIAGNOSED BY: PHONE |COMMUNICABLE DISEASE? |

| | |Health notebook-Diagnosed Condition pg |

|Health notebook-Diagnosed Condition page |Health notebook-Diagnosed Condition pg | |YES | |NO | |UNKNOWN |

|HEALTH PROBLEM DESCRIPTION |

| |Health notebook-Diagnosed Condition page |

|TREATMENT PLAN / INSTRUCTIONS |

| |Health notebook-Diagnosed Condition page |

!@#$%(1)

| WELL CHILD EXAM |

|DATE |EXAM TYPE |SERVICE PROVIDER |

|Health Notebook – Well Child Page|Health Notebook – Well Child Page |Health Notebook – Well Child Page |

|(Contact notebook-Associated | | |

|Services page) | | |

|AGE AT TIME OF EXAM |HEIGHT | HEIGHT % |WEIGHT |WEIGHT % |HEAD CIRCUMFERENCE |

|Client notebook-ID page |Health Notebook – Well |Health Notebook – Well |Health Notebook|Health Notebook – Well |Health Notebook – Well Child Page |

| |Child Page |Child Page |– Well Child |Child Page | |

| | | |Page | | |

|COMMENTS / OUTCOMES / REFERRALS |

| |Health Notebook – Well Child Page |

!@#$%(2)

|IMMUNIZATIONS |

|IMMUNIZATION TYPE |DATE GIVEN OR WAIVED |WAIVED |SOURCE OF INFORMATION / CLINIC / PHYSICIAN |NEXT DUE DATE |

|Health notebook-Immunization page|Health notebook-Immunization | |Health notebook-Immunization page |Health |

| |page | | |notebook-Immunization page|

!@#$%(3)

|CURRENT HEALTH SERVICE PROVIDERS |

|Health notebook-Summary page |

|CURRENTLY RECEIVES SERVICES FROM: | |CA CHILDREN’S SERV | |REGIONAL CENTER | |OTHER | |

|SERVICE PROVIDER NAME |SERVICE PROVIDER TYPE |DATE LAST SEEN |

|Client notebook-Service Providers page – providers listed on this |Service Provider notebook-ID page |Contact notebook-Associated Services page |

|page with no end date will populate here. | | |

|CLINIC/AGENCY NAME, IF ANY |ADDRESS |

|Service Provider notebook-ID page | |

|PHONE |Service Provider notebook-Address page |

|Service Provider notebook-ID page | |

!@#$%(4)

|PAST HEALTH INFORMATION |

|BIRTH HISTORY |

|BIRTH PLACE / HOSPITAL NAME |BIRTH LOCATION (CITY COUNTY STATE AND COUNTRY) |

|Health notebook-Birth History page or Client Notebook – |Health notebook-Birth History page or Client Notebook – Demog Page |

|Demog Page | |

|WEIGHT |LENGTH |HEAD CIRCUMFERENCE |APGAR |GESTATION AGE |

|Health notebook-Birth History |Health notebook-Birth History page |Health notebook-Birth History |Health notebook-Birth History |Health notebook-Birth |

|page | |page |page |History page |

|TOXICOLOGY SCREENING |NEWBORN SCREENING RESULTS |

|Health notebook-Birth History page | |

|PRENATAL / PERINATAL COMMENTS | |

| |Health notebook-Birth History page |

|PAST HEALTH ISSUES |

|Each Health Problem with an end date is followed by related information from the Health notebook-Medications, Hospitalizations, Medical Tests, and Referrals pages. |

|HEALTH PROBLEM |ONSET DATE/FIRST VISIT |END DATE |

|Health notebook-Diagnosed Condition page |Health notebook-Diagnosed Condition page |Health notebook-Diagnosed Condition page |

|DIAGNOSED BY: NAME |DIAGNOSED BY: PHONE |COMMUNICABLE DISEASE? |

| | |Health notebook-Diagnosed Condition page |

|Health notebook-Diagnosed Condition page |Health notebook-Diagnosed Condition page | |YES | |NO | |UNKNOWN |

|HEALTH PROBLEM DESCRIPTION |

| |Health notebook-Diagnosed Condition page |

|TREATMENT |

| |Health notebook-Diagnosed Condition page |

!@#$%(5)

|PAST HEALTH SERVICE PROVIDERS |

|Health notebook-Summary page |

|PREV. RECEIVED SERVICES FROM: | |CA CHILDREN’S SERV | |REGIONAL CENTER | |OTHER | |

|SERVICE PROVIDER NAME |SERVICE PROVIDER TYPE |DATE LAST SEEN |

|Client notebook-Service Providers page – providers listed on this |Service Provider notebook-ID page |Contact notebook-Associated Services page |

|page with End Date | | |

|CLINIC/AGENCY NAME, IF ANY |ADDRESS |

|Service Provider notebook-ID page |Service Provider notebook-Address page |

|PHONE | |

|Service Provider notebook-ID page | |

!@#$%(6)

|FAMILY MEDICAL HISTORY |

|MATERNAL - SIGNIFICANT HEALTH PROBLEMS | |

| |Health notebook - Birth History page |

| |

|PATERNAL - SIGNIFICANT HEALTH PROBLEMS | |

| |Health notebook - Birth History page |

|EDUCATION INFORMATION |

|PARENT(S) / GUARDIANS EDUCATIONAL RIGHTS LIMITED? | |YES | |NO |

|Education notebook-Enrollment Information page or Client Notebook-Demog Pg | | | | |

|COURT APPOINTED EDUCATION REPRESENTATIVE |PHONE NUMBER |

|Education notebook-Enrollment Information page |Education notebook-Enrollment Information page |

|DOES THE CHILD HAVE AN INDIVIDUALIZED EDUCATION PROGRAM (IEP/IIFSP)? |

|Education notebook-Grade Level Information page – IEP recorded as an Education Record |

| |Client notebook- Demographics page |

|ARE TRANSITIONAL INDEPENDENT LIVING SERVICES BEING PROVIDED? | |YES | |NO |

|Case Plan notebook-Planned Client Services page – ILP Services recorded here. | | | | |

|HAS THE CLIENT COMPLETED AT LEAST ONE SEMESTER OF COLLEGE? | |YES | |NO |

|Education notebook-Enrollment Information page | | | | |

|HAS THE CLIENT ATTENDED POSTSECONDARY/VOCATIONAL TRAINING? | |YES | |NO |

|Education notebook-Enrollment Information page | | | | |

|CLIENT SPECIAL EDUCATION |

|INSTRUCTION RECEIVED? |START DATE |END DATE |

|Education notebook-Enrollment | | |

|Information page | | |

| |YES | |NO |Education notebook-Enrollment |Education notebook-Enrollment Information page |

| | | | |Information page | |

!@#$%(11)

|CURRENT |

|Education Notebook for a child completed with a start date and no end date will appear as the current school. |

|SCHOOL NAME |PHONE |

|Education Provider notebook-ID page |Education Provider notebook-ID page |

|SCHOOL ADDRESS: |

|Education Provider notebook-Address page |

| |

|CONTACT NAME |START DATE |

|Education Provider notebook-Contact page |Education notebook-Enrollment Information page |

|EXPLANATION IF CHILD WAS NOT PLACED IN PROXIMITY OF PREVIOUS SCHOOL ENROLLMENT |

| |Placement notebook-ID page |

|SPECIAL EDUCATION NEEDS OF THIS CHILD |

| |Education notebook-Enrollment Information page |

|GRADE |GRADE LEVEL PERFORMANCE |TEACHER / COUNSELOR NAME |START DATE |

|Education |Education notebook-Grade Level |Education notebook-Grade Level Information page |Education notebook-Grade Level Information page |

|notebook-Grade Level |Information page | | |

|Information page | | | |

|Educational Needs / School Performance / Strengths / Interests |

| |Education notebook-Grade Level Information page |

!@#$%(7)

|PREVIOUS |

|Education Notebooks for a child that are ‘end dated’ will appear in this section. |

|SCHOOL NAME |PHONE |

|Education Provider notebook-ID page |Education Provider notebook-ID page |

|SCHOOL ADDRESS: |

|Education Provider notebook-Address page |

| |

|CONTACT NAME |START DATE |END DATE |

|Education Provider notebook-Contact page |Education notebook-Enrollment |Education notebook-Enrollment Information page |

| |Information page | |

|REASON CHILD LEFT SCHOOL |

|Education notebook-Enrollment Information page |

|SPECIAL EDUCATION NEEDS OF THIS CHILD |

| |Education notebook-Enrollment Information page |

|GRADE |GRADE LEVEL PERFORMANCE |TEACHER / COUNSELOR NAME |START DATE |END DATE |

|Education |Education notebook-Grade Level |Education notebook-Grade Level Information page |Education notebook-Grade|Education notebook-Grade|

|notebook-Grade Level |Information page | |Level Information page |Level Information page |

|Information page | | | | |

|Educational Needs / School Performance / Strengths / Interests |

| |Education notebook-Grade Level Information page |

!@#$%(8)

-----------------------

Example: Searching for the provider: Financial First

Surrounding the word ‘financial’ with the percent signs – is asking for any provider with the word financial in it.

Parental Consent/Court Order date here

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