Reason child entered care:
Previous placement history, including current placement. (place/dates/reason for replacement)
School Information: If in school, please provide the school name, grade, and current type of school setting. Please list all previous schools attended.
Describe any special education services the child receives — Is an IEP or a 504 Plan in place?
List types and location of all psychiatric services received. (Including hospitalizations)
Has the child experienced suicidal ideation and/or had suicide attempts? If Yes, please describe dates, method and services provided.
Do you or the caregiver have any concerns regarding speech or other OT concerns? If so, what are the concerns? Has the child been receiving services in this area—with whom?
Mediciation, if yes, please indicate type and why prescribed
Describe personality and strengths of child *
Physical health issues
Caseworker’s goal for treatment—what do you and the caregivers see as the primary issues? *
Does the child have a current visit schedule? What is the child’s permanency planning goal?
