CHILD INFORMATION FORM - Missouri Department of Social ...
[pic] |CHILD INFORMATION FORM FOR RESPITE PROVIDER
MISSOURI DEPARTMENT OF SOCIAL SERVICES
CHILDREN’S DIVISION | |
I. RESPITE INFORMATION:
Child's Name: Child's DOB:
Child's Medicaid Number/DCN:
Respite dates: to Drop off time: am/pm Pick up time: am/pm
Emergency Numbers: Foster Parent
Social Worker: Child's Physician ________
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II. CHILD’S BACKGROUND:
A. Check all that apply to the child:
Strengths
| Helpful | Intelligent | Honest | Enjoys art | Dependable | Articulate |
| Good hygiene | Enjoys sports | Enjoys music | Interacts well | Respects authority | Well-Mannered |
| | | |w/others | | |
| Accepts change | Generous /Shares | Good with younger | Leadership qualities | Accepts diversity in | Compassionate |
| | |children | |others | |
Needs Support
| Honesty | Bedwetting | Being Safe | Sharing | Hygiene | Toilet training |
| Anger Management | Not acting out | Nightmares / Insomnia | Supervision around pets| Keeping things orderly| Tolerating redirection |
| |sexually | | | | |
| Accepting | Not taking others | Understanding due to lower | Close supervision by | Supervision w/younger| Mental limitations and |
|responsibility for |property |IQ |caring adult |kids |abilities |
|behavior | | | | | |
B. Check all that apply to the child:
Suicidal Physically Aggressive Verbally Aggressive
Sexually inappropriate Destruction of Property Fire-Setting
Crimes-Delinquency Sexually Active Substance Abuse
Depression Elopement Medication needed
Medical (explanation e.g.: broken arm) ___________________________________
1. List diagnosis: __ ___________________________________________________________
2. List all medications, time, and dosage: ______________________________________________________________________
__________________________________________________________________
III. RESOURCE PARENT CHECKLIST:
(Resource parent, please provide the following to the respite provider)
Placing Foster Parent has notified the child's case manager of respite details,
dates, Respite Provider, and phone number
Medicaid number
Health information, social worker information, child information
Inventory: clothing, special equipment, eye glasses, toiletries e.g. toothbrush
________________________ ___________________
Resource Parent's Signature Date
................
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