Information for Foster Parents - Part B, CFS-872B



Information for Out-Of-Home Care Providers – Part BUse of form: The information contained in this form must be provided to the out-of-home care provider before the prospective out-of-home care provider agrees to placement of the child or no later than seven days after the child is placed with the out-of-home care provider. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. If additional space is needed when completing this form, attach additional sheet(s).I.GENERAL INFORMATIONDate Form Filled Out (mm/dd/yyyy) FORMTEXT ?????Out-of-Home Care Provider: FORMTEXT ?????A.Child InformationFull Name – Child (Legal) FORMTEXT ?????Birthdate (mm/dd/yyyy) FORMTEXT ?????Social Security Number FORMTEXT ?????Race FORMTEXT ?????Ethnicity FORMTEXT ?????Gender FORMCHECKBOX Male FORMCHECKBOX Female FORMCHECKBOX OtherII.PLACEMENT REASON(S) FORMCHECKBOX Child abuse or neglect (CAN) FORMCHECKBOX Physical FORMCHECKBOX Sexual abuse FORMCHECKBOX Emotional abuse FORMCHECKBOX Neglect FORMCHECKBOX Delinquent act(s) FORMCHECKBOX Assaultive FORMCHECKBOX Non-assaultive FORMCHECKBOX Developmental needs FORMCHECKBOX Medical needs FORMCHECKBOX Substance use FORMCHECKBOX Emotional needs FORMCHECKBOX Behavioral needs FORMCHECKBOX Life functioning needs FORMCHECKBOX Death, illness, or incarceration of primary caregiver FORMCHECKBOX Yes FORMCHECKBOX NoCHIPS, other than CANType of CHIPS / JIPS / Delinquency FORMTEXT ?????Nature of Offense(s) FORMCHECKBOX Property FORMCHECKBOX AssaultivePlacement is: FORMCHECKBOX Voluntary FORMCHECKBOX Court orderedOther Placement Reasons – Specify. FORMTEXT ?????III.SIGNIFICANT CONTACTSA.Legal Custodian / Guardian Full Name FORMTEXT ?????Relationship (Legal Custodian / Guardian) FORMTEXT ?????Address (Street, City, State, Zip Code) FORMTEXT ?????Telephone Number FORMTEXT ?????B.Guardian ad litem (GAL) and Legal CounselFull Name FORMTEXT ?????Relationship FORMCHECKBOX GAL FORMCHECKBOX Legal CounselAddress (Street, City, State, Zip Code) FORMTEXT ?????Telephone Number FORMTEXT ?????Full Name FORMTEXT ?????Relationship FORMCHECKBOX GAL FORMCHECKBOX Legal CounselAddress (Street, City, State, Zip Code) FORMTEXT ?????Telephone Number FORMTEXT ?????C.Other Individuals / ContactsFull Name FORMTEXT ?????Relationship FORMTEXT ?????Type of Contact FORMTEXT ?????Telephone Number FORMTEXT ?????Full Name FORMTEXT ?????Relationship FORMTEXT ?????Type of Contact FORMTEXT ?????Telephone Number FORMTEXT ?????IV.PLACEMENT HISTORY AND PERMANENCE GOAL(S)A.Previous Placement (If there is no court order prohibiting release of name of previous out-of-home care provider(s))Placement Type(FH, GH, RCC, hospital, etc.)Full NamePlacement DatesFrom(mm/dd/yyyy)To(mm/dd/yyyy) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????B.Permanence GoalPermanence Goal FORMCHECKBOX Reunification FORMCHECKBOX Guardianship FORMCHECKBOX Adoption FORMCHECKBOX Placement with a fit and willing relative FORMCHECKBOX Other Permanent Planned Living ArrangementWhat is the anticipated date the permanence goal will be achieved? FORMTEXT ????? (mm/dd/yyyy)Concurrent Goal FORMCHECKBOX Reunification FORMCHECKBOX Guardianship FORMCHECKBOX Adoption FORMCHECKBOX Placement with a fit and willing relative FORMCHECKBOX Other Permanent Planned Living ArrangementWhat is the anticipated date the permanence goal will be achieved? FORMTEXT ????? (mm/dd/yyyy)V.TRAUMA HISTORYA.Sexual Abuse HistoryYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History of sexual abuseSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Any involvement of the child as a victim in sexual intercourse, sexual contact, prostitution (s. 944.30), sexual exploitation of a child, causing a child to view or listen to sexual activity (s. 948.055)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Perpetrator was known to the child (e.g., close relationship, family, etc.)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Abuse occurred multiple timesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Abuse occurred over a period longer than 6 monthsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Threat of force or physical force was used during the abuseSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lack of support from close family members of abuse disclosureSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????B.Trauma HistoryYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Child is a victim of sex traffickingSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical abuseSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NeglectSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Emotional abuseSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical traumaSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Child has experienced a natural disasterSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Child has witnessed family violenceSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Child has witnessed community violenceSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Victim of criminal activity or witnessed the victimization of a family or friendSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????C.Adjustment to TraumaYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Problems with affect regulation (e.g., exaggerated emotional response)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Re-experiences the trauma (e.g., sleep disturbance, nightmares)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Increased arousalSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adjustment problems (e.g., PTSD, flashbacks, nightmares, anxiety)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Experiences episodes of dissociation (e.g., avoids thoughts/feelings associated with the trauma, unable to recall a specific event, etc.)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty with a numbing response (e.g., flat emotional state, detached)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traumatic grief due to death or the separation from caregiverSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Experiences intrusive thoughtsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????VI.SCHOOL / CHILD CAREA.Educational NeedsYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty getting along with teachersSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty getting along with peersSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extra time spent with child on required school activities (e.g., homework)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Attendance / Truancy issues, unrelated to school suspensionsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Disruptions at school or day careSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Clings excessively to parent, teacher or otherSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frequent suspensions or expulsionsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX School / childcare does not meet the needs of the childSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty with achievement (e.g., low grades, failing some subjects)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Child receives services for:Specify: FORMTEXT ????? FORMCHECKBOX Autism Spectrum Disorder FORMCHECKBOX Significant development delay FORMCHECKBOX Cognitive disabilities FORMCHECKBOX Specific learning disabilities FORMCHECKBOX Emotional behavioral disabilities FORMCHECKBOX Speech / language impairment FORMCHECKBOX Hearing impairment FORMCHECKBOX Traumatic Brain Injury FORMCHECKBOX Orthopedic impairment FORMCHECKBOX Visual impairment FORMCHECKBOX Other health impaired FORMCHECKBOX Other FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????VII.LIFE FUNCTIONINGA.DevelopmentalY NUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Significant delays in cognitive functioningSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Reliant on caregiver to functionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Unable to indicate wants and / or needsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty understanding simple routines or simple tasksSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Meets diagnostic criteria for autism disorderSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Limited communication skills or is unable to communicateSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Requires excessive verbal prompting on self-care tasks or daily living skillsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Requires assistance on self-care tasks (e.g., eating, bathing, dressing, etc.)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fine or gross motor skill delaysSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????MedicalY NUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical illness which requires medical treatment / interventionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Life threatening illness or medical conditionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical condition with risk of premature death (e.g., prior to adulthood)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lifelong medical condition (e.g., no expectation to fully recover)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Concern about the accuracy of the medical diagnosisSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Child has difficulty coping with the medical conditionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Interferes with functioning in more than one life domainSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical condition requires daily and invasive medical treatment Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical condition requires taking multiple medications Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????Health Concerns or SymptomsYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below.Brain or head concerns FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Serious head injury or loss of consciousnessSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Headaches, migraines, dizziness, coordination or balance challengesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Traumatic Brain InjurySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????Heart and lungs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Short of breath, swollen anklesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX High or low blood pressureSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Heart trouble or murmur, chest pain, irregular heartbeat Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Flu, pneumoniaSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Wheezing, bronchitisSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX AsthmaSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????Skin conditions or allergies FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lice, scabies, wormsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Chronic diaper rash, impetigoSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Treatment for skin trouble, rashes, hives, breaking out, acneSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX EczemaSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????Eye, ear, nose, throat or dental problems FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Trouble swallowing, speaking, persistent hoarsenessSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Chronic or severe ear or sinus infectionsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Blocking of nose, discharge, post-nasal dripSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Severe or painful dental problemsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Blindness, blurred, or double vision.Date of last eye exam: FORMTEXT ????? (mm/dd/yyyy)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hearing problems, ringing ears, discharge / infection, tubesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sensory disorder/diagnosisSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????Systemic conditions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ColicSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Numbness or loss of strength in hand, arm or legSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Urinary, prostate, gall bladder, kidney problemsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Reflux, choking, heartburn, ulcersSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Constipation, diarrhea, blood in stool, uses laxativesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Incontinent, encopreticSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sprain or dislocation of bone or joint; e.g., brittle bones or rolling jointsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Arthritis, backaches, cramps, bursitis, or pain in legsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????Risk factors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Low birth weightSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lack of prenatal careSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Born premature or overdueSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Complications at birthSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX In utero exposure to alcohol and /or drugsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????D.Medical Illness or DiagnosisYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Check illness child has had, as applicableSpecify: FORMTEXT ????? FORMCHECKBOX 7-day measles FORMCHECKBOX Rubella FORMCHECKBOX Chicken pox FORMCHECKBOX Scarlet fever FORMCHECKBOX German measles FORMCHECKBOX Strep throat FORMCHECKBOX Covid 19 FORMCHECKBOX Whooping cough FORMCHECKBOX Mumps FORMCHECKBOX Other FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PolioSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hepatitis BDate of last test: FORMTEXT ????? (mm/dd/yyyy)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Tuberculosis (TB)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX AIDS / HIVDate of last test: FORMTEXT ????? (mm/dd/yyyy)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Mononucleosis, thyroid problemsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Hemophilia, Sickle Cell anemiaSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lead poisoningSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Liver diseaseSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DiabetesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Seizure disorder, epilepsySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cerebral Palsy, Muscular DystrophySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Down’s SyndromeSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cancer, leukemia, or other malignancySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Failure to ThriveSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????E.Medical Appointments and TreatmentYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frequent therapeutic exercises done by child with provider’s helpSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Requires care of medical equipmentSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frequent doctor visits or hospitalizationsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical tests (Check those that apply and when the tests were completed) FORMCHECKBOX CAT scan FORMTEXT ????? (mm/dd/yyyy) FORMCHECKBOX MRI FORMTEXT ????? (mm/dd/yyyy) FORMCHECKBOX Chest x-ray FORMTEXT ????? (mm/dd/yyyy) FORMCHECKBOX Pap test FORMTEXT ????? (mm/dd/yyyy) FORMCHECKBOX EEG FORMTEXT ????? (mm/dd/yyyy) FORMCHECKBOX TB skin test FORMTEXT ????? (mm/dd/yyyy) FORMCHECKBOX EKG FORMTEXT ????? (mm/dd/yyyy) FORMCHECKBOX Other FORMTEXT ????? (mm/dd/yyyy) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Recent hospitalizationSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????F.Other Life Functioning NeedsYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty in social relationships with same age peersSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty in social relationships with adultsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX No engagement or interest in recreational activitiesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Does not sleep through the night, including nightmares , sleepwalkingSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Wets the bedSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Concerns with independent living (e.g., difficulty with cooking and / or cleaning, problems with money management)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty in relationships with parents and / or siblings (e.g., arguing, difficulty in maintaining a positive relationship)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????VIII.ACCULTURATION NEEDSA.Cultural IdentityYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX English as a second language / needs a translator Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Struggles with cultural identitySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Needs assistance with creating connections to others who share his / her cultural identity Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Needs support to practice cultural rituals Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????IX.EMOTIONAL NEEDSA.AttachmentYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lack of concern for others, lack of remorse or conscienceSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty communicating with others, does not vocalize or maintain eye contactSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Avoids emotional situations and personal relationshipsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Excessively / inappropriately seeks attentionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty establishing and maintaining attachment to caregiverSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Over or under-reacts to separation from caregiver during transitionsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Over or under-reacts to family interactionsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficulty making and maintaining friendshipsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Multiple placementsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lack of boundaries with strangers; lack of fearSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????B.Attention or Functioning LevelYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Needs close or constant supervisionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extreme hyperactive and impulsive behaviorsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Refuses or is unable to follow instructions or rules (non-academically)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Has difficulty focusing or sustaining attention in home environmentSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Needs structured behavior management, fails to respond to limit-setting or disciplineSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????C.Mental Health NeedsYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History of mental health needs or diagnosis in familySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Suicidal riskSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-injurious (e.g., intentionally harms self)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other self-harm (e.g., reckless, risk-taking behavior)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lethargic, apathetic, withdrawn, unresponsiveSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Psychosis (e.g., hallucinations, delusions, bizarre behavior)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extreme fears or phobiasSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frequent mental health treatment or hospitalizationsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Psychiatric diagnosisSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX AnxietySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DepressionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ExploitedSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????D.Other Emotional NeedsYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Difficult to soothe or console; unexplained, excessive, or prolonged crying spellsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Displays emotions that are inappropriate to the situationSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Is preoccupied with routine, objects, or appearanceSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frequent or excessive temper tantrums or rageSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Takes unusual risks with personal safetySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement in activities that are harmful to the child’s physical, mental or moral well-beingSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Somatization (e.g. persistent physical symptoms without a medical cause, such as headaches)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????X.BEHAVIORAL NEEDSA.Dietary Needs or ConcernsYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Persistent or ongoing feeding problemsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Gorges or hoards foodSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Eats non-food itemsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Eating disorder; excessive preoccupation with food, weight, or body imageSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Dramatic weight gain or lossSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Special diet needs or limitationsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Picky eaterSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Binge eatsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History of hospitalization(s) as a result of an eating disturbanceSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????B.Substance Use or AbuseYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Tobacco useSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Fetal alcohol effects or syndromeSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History of drug dependency or AODA issues in familySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History of abusing over the counter or prescribed medicationsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Alcohol or drug use; use or abuse of household items or chemicals for other than intended purposesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????C.Sexual Development and / or BehaviorsYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Any involvement of the child as a perpetrator in sexual intercourse, sexual contact, prostitution (s.944.30), sexual exploitation of a child, causing a child to view or listen to sexual activity (s. 948.055)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Inappropriate sexual behaviors, displays overt sexual gestures, language, or dressSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Unusual or painful menstruationSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual activitySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Use of birth control, medication, or other birth control methodsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexually transmitted diseaseSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Expectant parent or parentingSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Medical complications resulting from an abortionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Anxiety associated with sexual identitySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX High-risk sexual behaviors (e.g., multiple partners, older partners, prostitution)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sexual aggressionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????The child identifies as: FORMTEXT ?????Specify: FORMTEXT ?????D.Violence or AggressionYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Association with a gang or any other group harmful to self or othersSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extremely destructive to propertySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Threatened or assaulted anyone physically Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Abused or acts cruel to animals – physically or sexuallySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Bullies or instigates situations or fightsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Verbally aggressiveSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Inappropriate use of weaponsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????LegalYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement in the legal systemSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Engagement in delinquent behaviorSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History of arrestsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Plans criminal / delinquent behavior, premeditated behaviorSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Behavior places community residents at risk of harmSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Does not comply with court sanctions / ordersSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Influenced by parental criminal behaviorSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Influenced by environment to engage in criminal / delinquent behaviorSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????RunawayYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX History of running away from homeSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Runs frequently, runs at every opportunity, or has run on multiple occasionsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Consistently runs to the same location, neighborhood, or communitySpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Runs to unsafe environments; likelihood of victimization is highSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Engages in delinquent and / or dangerous activities while on the runSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Others encourage or help youth to runSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Unrealistic expectations of the consequence of his / her running behaviorSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????Other Behavioral NeedsYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Sets fires Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Self-stimulating behaviors or repetitive body motionsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Unusually accident proneSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Extremely sensitive to outside stimuli – fabrics, smells, noise, temperature, or clothingSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Smears fecesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX StealsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Habitually liesSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Shows bizarre or disturbed thoughts or behaviors (e.g., death, weapons, fire, etc.)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OppositionalSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Antisocial behaviors (e.g., lying, stealing, manipulation, etc.)Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Behavioral regressionSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Intentional misbehaviorSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Atypical behaviors (e.g., head banging, smelling objects, spinning, twirling, hand flapping, finger-flicking) Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????XI.OUT-OF-HOME CARE PROVIDER QUALIFICATIONS OR NEEDSYNUCheck Y (Yes), N (No) or U (Unknown) for each category listed below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frequent and long-distance transportationSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Frequent family interaction visitsSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Transportation to school of originSpecify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Involvement in medical or therapy appointments Specify: FORMTEXT ????? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX OtherSpecify: FORMTEXT ?????XII.IMPORTANT DOCUMENTSThe placing agency has given the out-of-home care provider (s): (Check all that apply.) FORMCHECKBOX Birth certificate (copy) FORMCHECKBOX School academic records*, including IEP FORMCHECKBOX Court order* FORMCHECKBOX Signed medical release for emergency health care FORMCHECKBOX Court report* FORMCHECKBOX Social history* FORMCHECKBOX Dental records* FORMCHECKBOX Social Security card FORMCHECKBOX Information on diagnosis FORMCHECKBOX Summary of mental health treatment* FORMCHECKBOX MA card FORMCHECKBOX Summary of social / psychiatric evaluations* FORMCHECKBOX Medical records – including immunization record* FORMCHECKBOX Other – Specify: FORMTEXT ????? FORMCHECKBOX Placement agreement FORMCHECKBOX Other – Specify: FORMTEXT ?????*Summary is requested to ensure that materials can be interpreted by the out-of-home care provider(s). Primary source documents can be provided if useful for clarification. This form and the information included herein have been shared with the out-of-home care provider(s).XIII.PLAN FOR MANAGING CHALLENGING BEHAVIORSDescribe any special skills or knowledge the out-of-home care provider will need to acquire to meet the needs of the child and handle the behaviors of the child in a safe manner. FORMTEXT ?????List the child’s behaviors that may lead to health or safety concerns. FORMTEXT ?????Describe warning signs of a developing crisis. Describe actions or situations that may cause the child anxiety or to act out. FORMTEXT ?????Describe steps to take in responding to an emergency or crisis. This should include interventions that have worked in the past and steps that should be taken if the child’s behaviors or emotions begin to escalate or worsen. FORMTEXT ????? FORMTEXT Describe the agency’s reporting requirements and debriefing procedures for emergency situations. FORMTEXT ?????If the child has a history of running away, describe the primary factors that have previously contributed to the child’s missing episode. FORMTEXT ?????If the child has a history of running away, describe any plans or interventions that should be put in place to ensure the child’s safety, well-being, and prevention of running in the future. FORMTEXT ?????XIV.CONSIDERATIONS FOR CONFIRMING SAFE ENVIRONMENTS FORMCHECKBOX Additional or special training for the out-of-home care provider. FORMTEXT ????? FORMCHECKBOX Additional contact by the agency or other providers. FORMTEXT ????? FORMCHECKBOX Rearrange the living environment. FORMTEXT ????? FORMCHECKBOX Closer supervision of children by caregivers. FORMTEXT ????? FORMCHECKBOX Additional house rules. FORMTEXT ????? FORMCHECKBOX Install special equipment (e.g., ramp, electrical generator, door alarm, etc.). FORMTEXT ?????XV.SIGNATURES FORMTEXT ????? FORMTEXT ?????SIGNATURE – Child Welfare Professional Date Signed FORMTEXT ????? FORMTEXT ?????SIGNATURE – Out-of-Home Care ProviderDate Signed FORMTEXT ????? FORMTEXT ?????SIGNATURE – Out-of-Home Care ProviderDate Signed ................
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