Post on 25-Jun-2018
Center for Family § Child Enrichmet, Inc
c/ier«/jrrujOMr Oplincn Since HJ77
PLACEMENT A/Foster Home
P Shelter Residential Facility Group Home
Relative Other
_ / _ Date Placed
/ COURT DATE
V I S I T A T I O N R E P O R T S
DATE of VISIT ^ 7 / ^ V ^ ^ ^ E X T CQUl NAME of Child / / < ^ 0 6 ^ ^ / P o C p ) ^ . DOB 6 S X _ ^ _ ^ d _ _ NAME/ADDRESS QF PLACEMENT <3-<^r/haTj ? J & I C J L .^y^i^m?
ZIP COPE ^ T A ^ S Relationship XP^,f^'p^A.^(p ,^yu2^i^
VISIT: ANNOUNCED ' ^ U N A N N O U N C E D NAME of COUNSELOR / ^ ^ i ^ g ^ i ^ 7 P l > & < ^ T E \ . V p p ^ ^ A 3 UNIT , ^ A /
EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE./ Complete blanks with yes or no and describe status. 1. CONDITION QF HQME Acceptable Environment Safe for Child Sufficient Food Toys/Play area
DESCRIBE" AjtyAJL- (?yn4yi^i^n^niji'7^^ / p AxP -yj- a^t-icp / MJZAT- <g ^
V E . /
d / ^ ^ . . 3 ^ AT number of occupants in the home changed^ Yes No
If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name DQB SS#
2. CONDITION ofCHILD Healthy, 'lAQ- WellNourished Placement Appropriate leWAbus
Behavior Signs of Neglefet/Abuse y J O
OBSERVATIONS o^CHILD
e > < ^ ^ i - ^ ^ ^ HOTLINE/LICENSING notified
4£m, ± IILD 7 ^ ^ CPXAQCAA^ yJpJLAJL. CAyj^j^^O^ - ^ Cd..^>y-^ />L^r^P-&^^
a ^ ^ & U J F
slame: Sell 3. SERVICES NEEDED Name Neighborhood Center Health Care: Medical Counseling/Therapy Developmental: Early Intervention (i Independent Living: Assessment
chool Grade Day Care, / V I r f J
1^1^ Immumizations/vj^Dental AyHHearing/yn- Vision l^f-fir [ T Clothing /0 ,^>utor ing /
) AV/)- Substance AbuseNewbpm ^ „. . . , l ( T PTxxzyxXiaa. fii/fir Plan . N / A Pre;
Economic Services r ^ l \ Relative Caregiver KA Assessments: Comprenensive Follow up Actions
ental Health A J ^ - C M S P A SSI y / k Parenting Classes "fherapeutic \^^ation y\JAAL
DLRS MA ESPT_^^^j4^CRC,' m ent A J / ^ Curriculum / 0 / / j - Plan l y ^ - Pregnancy Service/JM-16+ /V^^ DJJ / J /7T >. / lative Caregiver K / I ^ Housing /J^Votational /V^^Domeslio Violence A PA\ Exit IiiteA'iews Apnr ywj-'Mental Health /0/y|Behavioral /yy^ubstance^buse ^/y^cademic/vZ/^Developmental P / p {
4. CLIENT RESOURCE RECORD (Blue Book Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card,
Current Reviewed Birth Certificate
Detention Order _ Case Plans ^ Judicial Review Social Study Reports_ MEDICAL Physician,
Last Seen by Doctor Hearing / / FSPT
Case Plans^
Day Care
tel Dental
Vision /
Annual Physical /_ Last Visit / /
/ Developmental Case Manager, tel
5. COUNSELOR OBSERVATIONS
^ 6. FOSTER PAREN
xiJyTTF4~Aji
OAQ I - ^ ^ mJAW02jJ^ I A M ! £ ^ ' f ^ P ( y ( ( 'Aiyy^9(i^
. T E R / R E L A ' I I V E / J C H O O L / P R O ^ E R COMMENTS PXo'- liZyO ( iy-eyf_ ^^VAflHpT^J
MK. P1\Q klX>vyy\STT ^
ISSUES re: SERVICES
7. CHILD'S C J O M M E N T S ^fOPAG. ^ l . £^y -y^ -pyi^ . <^M/.cyiA^^:pJAa^ V ^ rT^j .Pp-'JpP P d ^ P'^.^rPTp'
3GRESS TQWARDS GQAL ,- , / / 7 . , y) ,
9. FQLLOW UP/RECOMMENDATIQNS for NEXT VISIT
ID. FAMILY VISITATIQN Parents, OBSERVATIONS
Sibling, Therapeutic, Dates
Signature
T ^ . oPJdnATLT-^ iPTTTt date 'S igna tu re / / date Signature
COUNSELOR - PI/PS/FC SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Coun'selor visited
WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGFVER/PROVIDER
Child Enrichment, Inc cJierislim} OM cipiitKn Since 1077
PLACEMENT /Foster Home Shelter
/ _ / Date Placed
VISITATION REPORT SUMMARY
DATEofVISIT NAME of Child
T CQURT DATE / / / W ^ O
Residential Facility Group Home Relative Other
D Q B ^ / a ^ _ _ NAME/ADDRESS QF JLACEMENT ( '/^nm i n At^4 J C r X ^
, ziPCODE"^/^.r Relationship
VISIT: /NNOI NAME of COUNSELOR
tA. AaAJlyy<=P~^
m. T P A JANNOUN,CeD
Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION 1. CONDITION.OF HQME
Sufficient Foo^ y .^_S ' J Pys/Play a 1. CONDITION OF HQME Acceptable VJA .Environment Safe for Childj i J ^ D E s c m B E r ^ p ^ O r ^ - ^ P 6 P > ( P A Z P X P ^ ^
/) 1^ Pi,^ ^ / I XX y
' r T E L / ^ ^ ^ ^ U N I T / ^ ^ ^ 3N in fhe CASfe N X R R A T I V ] ^
'J
as the number OT occupant^n the home changed? Yes No - ' ^
Has the number rff occupant^n the home changed? If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name DQB SS#
2. COND Healthy Placement Appiropriate
Nof CHILD Well Nourished
Signs of] Behavior ^fe^//^^
:i^IN/j notffted E/LICENSING notifled // / ^yn/)
Neighborhood Center Health Care: Medical Counseling/Therapy Developmental Independent Living . , Economic Services J^y^Welatiy^Ca'regiver A^y^ousing ^A<* 'VopationalA / Assessments: Comprehfensive /v-fAJMental Healtllxy/^ehavioral Wj^ Substanc Follow up Actions Actions 0 f)
yAn^&PMT. Current 4. CLIENT RESOURCE RECORD (Blue Book Stays with Child) Available_
CONTAINS Medicaid/Medipass Card Copies ofSocial Security Card Detention Order Case Plans Judicial Review Social Study Reports
tel
Reviewed Birth Certificate
MEDICAL Physician, Last Seen by Doctor Hearing FSPT
/ / / /
Dental, Vision /
Day Care Aimual Physical_
Last Visit / / /
/ Developmental, Case Manager, tel
5. COUNSELOR OBSERVATIONlAuMi.c^ XM,/f jiy[Sl.UX{AUXA /2AAAyJfy.aP^cP ^ - ^ P ^ O L y j
^AlAyC&fnn r?
p A l ^ J 2 y i ^ A 0 X , y \ ! p - . fP(AP^a^Xyj0^AAPyJ>7aXZ^ -^AJAAX,.^Jay7.-Cf^ 1AP.Q^ OyiyiQQ(AUl 6. FOSTER PARENT/SHELTER/RELAmE/ZCbOOL/PROVIDERCQAlMENTS (f-^^^jgyLiZx^^oCA^A . ^ ^
h L y P l d f ' P ^ k . PA(xLCPlWy/A.lrPZ^6M^_.PPi(^y^ '
y • /JjACApT. r^yCA^. rJi AAriP e ,-
ISSUES re: S a ^ ^
7. CHILD'S CQMMENTS
8. PROGRESS TOWARDS GOAL (JAPlXA.Ql/A§A/T a pp . P^x^^TPM&ry
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
10. FAMILY VISITATIQN Parents, OBSERVATIONS
Sibling Dates
Signature Signature date
COUNSELOR - PI/PS/FC
Signature / / date
SUPERVISORY REVIEW CAREGFVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGFVER/PROVIDER
Chronological Notes Report
Case Name: ,
Note ID:105079205 Revision ID:1 Worker Creating Note:FRANCOIS, YVES, A
Case ID: 103027
Date Entered:07/15/2008 03:22 PM Worker Making Contact:FRANCOIS, YVES, A
Note Information Contact Begin date:07/l 5/2008 08:45 AM Category: Case Worker Activity Code:Case Management
Contact End date:07/l5/2008 09:15 AM Type:Reviews - Supervisory
Contact Information Inv/Assessment Number:
Subjects Contacted
Subjects Not Contacted
Other Subjects
Narrative MONTHLY SUPERVISORY REVIEW COMPLETED TODAY WIT HASSIGNED FULL CASE MANAGER, ROBERTA THEOC. NEITHER MS THEOC NOR THE CHILDREN'S CAREGIVERS HAVE REPORTED ANY CONCERNS AND/OR ISSUES RELATED TO THEIR SAFETY, WELL-BEING, PLACEMENT SETTING AND PERMANENCY PLANNING GOAL; HOWEVER, ALL HAVE EXPRESSED GREAT CONCERNS OVER THE LENGTHY DELAY IN RESOLVING THE FATHER'S APPEAL OF THE FINAL JUDGMENT OF TERMINATION OF PARENTAL RIGHTS. CASE MANAGER NEEDS T OCONTINUE FOLLOWING UP WITH MS RINALDI AT DCF LEGAL TO OBTAIN CURRENT STATUS OF THE APPEAL....YAF..../.
^»i: V
Center for liamily S ^ h i l d Enrichment, lnc
PLACEIVIENT Foster Home Shelter
^ * ' ^ / " ^ - ^
VISITATION REPORT SUMMARY
_ / / _ Date Placed
DATEofVISIT NAMEofChild NAME/ADDRESS OF PLACEMENT
I C ^ NEXT COURT DATE ^ f s / O t ^
DOBResidential Facility
_ Group Home Relative
~ Other
Relationship T - g ^ 4 e . r -j-jgM^'^-'—^ ZIP CODE
VISIT: ANNOUNCED/" UNANNOUNCEPSrH' r ^ / NAME ofCOUNSELOR fe4U^.^giLnXoJ>cj:EL3^f^g-^|^
Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE./ 1. CONDITION OF HOME Acceptable "^"^^^-^ Enviromnent Safe for OaxXiCC—C^A^— Sufficient Food ""T^y^-^* Toys/Play area DESCRIBE ^
)> -€ - - ^ Z S ^ ^ ^ C ' t ^ ^ ,
y ^ C>rY^LQS^
^cC^CC^CAA^&ACC^C^^ '^ Has(tne nuraber oi' - g r i J^ occupants m the home changed? No
If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name DOB SS#
2. CONDITION of CHILD Healthv > x H ^ WellNourished Placement Aiii)ropriate K \ C O SignsOBSERVATIONS ofCHIl
3 0fN( Behavior
'Abuse HOTLINE/LICENSING notified OBSERVATIONS ofCHILD € ^ 3 f-SA^-^J^-^rD-^-YyA r ^
•lea I I
JYL^ - C 3 A
Ajk J L ^ ^ - ^ ^
3. SERVICES NEEDED Name: School M ^ J U P ^ LQXSJCSL^ C £ - ^ Grade Day Care Neighborhood Center Health Care: Medical Immunizations Dental Hearing Vision Mental Health CMS Counseling/Therapy
SSI Clothing Tutoring
Developmental: Early Intervention (0-5) Independent Living: Assessment Economic Services Relative Caregiver Assessments: Comprehensive Follow up Actions
Substance Abuse Newbom Plan
Parenting Classes Therapeutic Visitation FDLRS FSPT CRC
Curriculum Pregnancy Services_ 16+ DJJ
Mental Health Housing Vocational_
Behavioral Domestic Violence Exit Interviews
Substance Abuse Academic Developmental_
4. CLIENT RESSDURCE RECORD (Blue Book Stays with Child) Available Current ^Reviewed CONTAINS Medicaid/Medipass Card Copies ofSocial Security Card Birth Certificate
Detention Order Case Plans Judicial Review Social Study Reports Day Care tel MEDICAL Physician_
Last Seen by Doctor_ Hearing / / FSPT
/ / Dental_ Vision /
Annual Physical /_ Last Visit / /
/ DeveIopmental_
5. COUNSELORfOBSERVAtlONS Case Manager_ tel
SH 6. FOSTER PARENT/SHELTE SHELTER/RELATIVE/SCHOOL/PROVIDER COMMENTS C '^-^\J\ Q.
c-VW>c^ .S j2JkrJ>\ V& - ^ ^ A Y ^
sh£ . ^ \> jCy-^O i l cxA^h- \^~jrC^gC^
r - ^ y JA S" \ o \ JPo
ISSUES re: 0 ^ —)-70
7. CHILD'S COMMENTS
8. PROGRESS TOWARDS GOAL a j t ^ 9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
10. FAMILY VISITATION Parents SERVATIONS
. Sibling Therapeutic_ Dates
«
Signature Signature date
COUNSELOR - PI/PS/FC
Signatiure/
SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Coun'selor visited
WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
Center for [amily S ^ i l d Enridiment. lnc ^ ^ B f t J ^ T i ^ i ' m n OHr d j i l imn Since 1977
PLACEMENT Foster Home Shelter Residential Facility Group Home
Relative Other
VISITATION REPORT SUMMARY
/ _ / Date Placed
DATEofVISIT NAMEofChild NAME/ADDRESS OF PLACEMENT
^ y ^ lyEXT COURT DATE S DOB < r m 6 a
x\r" c y r .fe><x'
Relationship l p < 5 . J ^ ^ ^ " VISIT: ANNOUNCED
NAMEofCOUNSELOR Complete blanks with yes or no and describe status. EXPLAIN OBSERVA 1. CONDITION OF HOME Acceptable / Environment Safe for Child_ DESCRIBE yC/iTYYl^ - ^ C J i u u ^
=3r" ZIP CODE
UNANNOUNCED,
X
^MJJATT^ ' T S ^ - ^ E L ^g-BIS'UNIT ^ { / "nONS/INFORMATION In the CASE NARRATIVE. \
Sufficient Fpod Sufficient Food Toys/Pky area
\;e>0 _ ^ gH-^^l^L-^ '^gai.^-^.g^^ Y-AJL.^_^ J / ^ .A.
^ " " ^ ^ ^ ^ - ^ /^^^J>-^
the^ .i?L'<f^^^-o c.^cs~v^
Has the^umber of occupants in the home changed? Yes No If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name DOB SS#
2. CONDITION of CHILD Healthy Placement
^OBSERV
^ , & A t L A ^ O^-^lr-i-J^
$ ^
S ' ^ ^ f i ^ HOTLINM^ENSMG notified / /
g - ^ ^ p >^-^ ^^, <Q>t—e
M 1 - ^ <^k^^ Q A - ^ . ^ CY r ^ - y ^ -^^
DED Name: { , J ^ CUl_ q^^L^Q--&^>--wa-£?/ A< <Y> ^ < ^
School Grade g/^'^Day Care
Health Care: Medical ^^/^mmunizations^ |A-Dentalyygi3Hearing Counseling/Therapy " ~ 1 _ , h / A ^ Clothing
3. SERVICES NEEDE Neighborhood Center
Vision Mental Health CMS SSI Counseling/Therapy Developmental: Early Intervention (0 Independent Living: Assessment ^ p r " Economic Services/V/w—Relatlvj
ag Tutorin; f^ubstancarAbuse Ne^wUny^^FDLRS
Durricyliun / y / A Plan tCyTk" P/egnan iyServices
Parenting Classes Therapeutic Visitation FSPT CRC
Assessments: Comprehensive Follow up Actions
g: Assessment A Y ^ Y Curricuhmi /y A" PlatirQ/yr Pregnamyi ^^>4~ReIati^ Caregiver^J7^4=;Housing "PAA^ 'Vocational'^/y^ 5rehensive_^^wKiental HealtliT^M^ ^Sehaviofal' Substance A
_16+_ ^ Domestic Violence
.DJJ Exit Interviews
Substance Abuse Academic Developmental,
Current 4. CLIENT RESOURCE RECORD (Blue Book Stays with Child) Available_ CONTAINS Medicaid/Medipass Card Copies ofSocial Security Card_
Detention Order Case Plans Judicial Review Social Study Reports
Reviewed Birth Certificate
MEDICAL Physician, tel Last Seen by Doctor_ Hearing / / FSPT
/ / Dental, Vision /
Day Care Annual Physical
Last Visit / / /
/ Developmental, Case Manager, tel
:OUNSELpR OBSERVA-TIONS . ^
Q A M U D^§lA^^_7b^.^cL W € ^ ^
6. FOSTER PARENT/SHteLTER/RELATIVE/SCHOOL/PRO
] y\ ^MjL N^X)gu:^o
DMlsiEN' FuX;
RCOMlNJfENTS V J l s ^ p t r r - ^ -^/vi^-Sr X / ^
} j l A r - ^
ISSUES re: SERVICES
7. CHILD'S COMMENTS
8. PROGRESS TOWARDS GO 7 ^
>7 l/-J^Oy\ - 0 ^ t 9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
10. FAMILY VISITATION Parents OBSERVATIONS
_ Sibling Therapeutic_ Dates
Signature date Signature date
COUNSELOR - PI/PS/FC
Signature c date
SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Coun'selor visited
WHITE COPY - CASE FDLE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
l v Center for Family^
«|[iild Enrichment, lnc
PLACEMENT V ^ o s t e r Home
/ _ / Date Placed
VISITATION REPORT SUMMARY
DATEofVISIT
r Shelter Residential Facility Group Home
Relative Other
Relationship VISIT: ANNO-
NAMEofCOUNSELO / UNANNOUNCED
/ //-g..o O T E L . ^ Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION In the CASE 1. CONDITION OF HOME Acceptable ~ A - ^ Environment Safe for Child "^^^^ Sufficient Food "^^Jiy^ Toys^lay^rea DESCRIBE/ /-/iryr-^^ ZY)
/l/t) A^ . .Y^
Qj-^rd c^-^OO 'yj^
A Has the numbff of occupants in the home changed? Yes No
/ C J V o j g ^
If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name DOB SS#
2. CONDITIO; Healthy,
OfCHILD Well Nourished"
Placement Appropriate BSERVATIONS o£ \'^~<^ \0YiCUl €
lA -*^ Behavii j YSigas ofNegl^t^use,
^ : ^
avion S ^ ^ < U ^ /cn^^^CU-.^ / A Q C^^YX^^ H0TLI5JE/LICBNSING notified^ 7
?g^
School 3. SERVICES NEEDED Nami Neighborhood Center Health Care: Medical Immuniz; Counseling/Therapy Developmental: Early Intervention (0-5) / ^ ISubstane e Independent Living: Assessment /y^QCurricuJui Economic Services /y/y')~Rela tiye Caregiver / y / Assessments: Comprehensive "" ' Follow up Actions
Day Care
fizatimis/il^ Dental/W-Hearing ^y>?"Vision/^^^ Y ^ / / T A \ A , . Cloming/^^ Tutoring, ^^^Y^^areptigg Classes Tiierapeutic
[oSr^^SubstaneeAbus ^ " ' • ^ ' - "^^" ' /^/<^un-icuj^m N / f f Pl;
Ibuse Newl^omW^^DLRS VAj- Pregnaney>Services
slaliye Caregiver /)v4: Hbusing/)0^ ^y^ 'C\Qri.A/y// Yiovc&^v ' '\o\&a.zt ffA/^ Exit Interview /W-Mental Health , jyhBehavifaral/ y>ijLSubstan6e Abuse/"^^ A)/gevelopmental
Current 4. CLIENT RESOURCE RECORD (Blue Book Stays with Child) Available_ CONTAINS Medicaid/Medipass Card Copies ofSocial Security Card,
Detention Order _ Case Plans Judicial Review Social Study Reports
Reviewed Birth Certificate
MEDICAL Phvsician Last Seen by Doctor / / Dental, Hearing / / Vision l_
Day Care tel Annual Physicalg^ i O'y
LastVisit I I Developmental,
FSPT Case Manager tel 5. COUNSELOR OBSERVATIONS WU0~&^ ^.^ f r ^ ^T^^^^^ 'A ' Z ^ T ^ ^ g t ^
OOL/PROVJDER COMMENTS . . e ^ ciy^j? , - 4 ^ /I'lA^TT^
6. FOSTER PARE »ARENT/SHEL1 /SHELTER/RELATIVES
^ A ^ C M 7 ^ jlAL. -- . i>JL<; y-xj
DRVICES * '-' ISSUES re: SERVICES
7. CHILD'S COMMENTS 0 ^ 0 / ^ ^ A^J_^C^YHO^ ^ i - K A i . i o o ^ '
8. PROGRESS TOWARDS GOAL rM<o;pgx>5v^ ^ f ^ d T f / ^ ^ ^
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
10. FAMILY VISITATION Parents
Signature date Signature
COUNSELOR
date
PI/PS/FC
s ta ture ' / date
SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
Center for FamilyS M|ildDii1climent,lnc
irdfllitKn: VISITATION REPORT SUMMARY
PLACEMENT yy^'Foster Home
Shelter
/ _ / Date Placed
04/d^/OE-DATE of VISIT NAME of Child ^^uUbCQu
MENTS
NEXT COURT DATE
, Residential Facility , Group Home Relative Other
NAME/ADDRESS OF PLACEMENT T CAArrne / c ^ -DOB s r ^ l iS^ooo
ZIP CODE Relationship
Complete blanks with yes or no and describe status. 1. CONDITION OF HOME Acceptable \ rS> , Environment Safe for Child DESCRIBE'' ^
VISIT: ANNQUNCED UNANNOUNCED NAME ofCOUNSELOR / 6 f e ^ ^ T X ^ < : ^ TEI^J^ j*-1^5" UNIT Qgl-<
EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE.
' ^ Sufficient Food njjLo Toys/Play area
/ Y ^ ^HLAJL-^ O ~ ^ \ J ^ ^A^^V^^^ "^SA^-'R'/C ' d Z - A ^ —pcCj tAjsSAQ
^ - ^ Q y - t i ^ ^ h " {'YvA:rry^~J? Yes \ y ^ No Has the number of occupants in the home changed?
If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name DOB SS#
2. CONDITION OfCHILD Healthv ^KffY\ Well Nourished_ Placement'Appropriate KA{9^ Signs of Ne lqctf Abuse_
OBSERVATIONS of < U 9 - ^ Signs of Negi CHILD A^O/fol
QCt7i £_ Behavior
/ O D ' >- <a-> /;2^<;gy^^.A^i-<3
'={^49<:,jC.£^:Jjl_. .-j:^. g o c J . H0TLIN6/LICENSIN'
jh^^iM^ &\Yjl<f^Aj^~P 3NSINC^notified V / ' ' ~
o/AeA^ (KhxJs^i^)-^ t J JOY) ' ^ ( 0 . ( L P Q ^
^%, <ci .ou>JiJA O >/ Q ^ ^ - ^ C ^
n ^X>y.ljCMQ-y^ C L - S - A ^ ^ — . (2iL^^- .a- .^^ .yUt:vti3>v-> v^ V-H-yK
3. SERVICES NEEDED Name: School_ Neighborhood Center /"^ f/K. Health Care: Medical Immunizations Counseling/Therapy
Day Care,
. ^)//9-7 Developmental: Early Intervention (^-5) /^ / /^ -Independent Living: Assessments^ / ^ Curriculum /V/V flan /^/yjt^i Economic Services f^f/^lative Caregiver /^^H6using/4^Vocati( Assessments: Comprehensive ^ / ' ' ^ " n t a l Health <rVlBehavioral fA(7\Su\
>q-CMS
ational^yy{-Domesticyiolence ^NSubstance Abuse/v^'Academic
•4^SI C/A, erapeutic Visitation / ^ A
^ C R C _ ^ ^ / DJJ YA//h
^ Exit Interviews ^developmental
Follow up Actions,
Current 4. CLIENT RESOURCE RECORD (Blue Book Stays with Child) Available_ CONTAINS Medicaid/Medipass Card Copies ofSocial Security Card,
Detention Order Case Plans Judicial Review Social Study Reports
Reviewed Birth Certificate
MEDICAL Physician, tel Last Seen by Doctor_ Hearing / / FSPT
/ / Dental, Vision /
Day Care Aimual Physical
Last Visit / / /
Developmental, Case Manager .
5. COUNSELOR OBSERVATIONS <^i^—/U''^ A A^dZtd^Yi 0 Y : ^ y \ £ L ^ 'Ld^zS2y ^^-^yyJe.^
6. FjOSTER PARENT/SHELTERJRELATIVE/SCHOOL/PROVIDER COMMENTS p^^oix>^/^ J U u ^ j y i y f N U M C O ^ O W - e / ^ y )^ \ jOY^ ^T7^'^2^ r^tX<^g£l-M^i— ^^^"'-^^!^^ . ^ / s . hCSL^ 4 A U J -
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
^
10. FAMILY VISITATION Parents BSERVATIONS
. Sibling. Therapeutic, Dates
Signature Signature date
COUNSELOR - PI/PS/FC
Signature / date
SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Coun'selor visited
WHITE COPY - CASE FE.E • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
^ ^ ' ^
O Center for Emilys igSild Enricliment. lnc
PL4f^EMENT Foster Home
' Shelter Residential Facility
, Group Home Relative Other
/ _ / Date Placed
VISITATION REPORT SUMMARY
DATEofVISIT NAMEofChild
ITSUMM^
0A16/^
VISIT NAME of COUNSELOR
UNCED ^ UNANNOIMgED _ / / / o ^ . /
lXaZlfe£^ T E £ 7 ^ ^ 2 « T ^ Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION in tjle CASE NARRATIVE. 1. CONDITIONjOF HOME ; ^ Acceptable y ^ V . Environment Safe for Cl) ld y-\jA> Sufficient Food \^C<:3/? _ To i /Play are^ DBSCBIBE/^:7^//7?^0," ^ 'W^ fkfmmwt( mm^ v/er
imlrer of th Has the number of occupants in the home changed? No If so, please list the name, date of birth and social security numl another foster child, please omit. Name DOB SS#
the new occupant(s). If the new occupant is
2. CONDITION of CHILD Healthv ^If^Si v /'^Jell Nourished
f PPrSpriate y Q ^ Si: IVATIOte-o/cHl lD
Placement / ppfSpriate
3.'SERVICES NEEDEDName: SchooXy^^ff /^y/CO/jQ^ - f t ^ ^ ^ K Grade / O ^ a y Care Neighborhood Center Health Care: Medical Immunizations Dental Hearing Vision Mental Health CMS Counseling/Therapy Clothing. Tutoring
SSI. Parenting Classes Therapeutic Visitation
FDLRS FSPT CRC Developmental: Early Intervention (0-5) Substance Abuse Newbom Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ DJJ Economic Services Relative Caregiver Housing Vocational Domestic Violence Exit Interviews Assessments: Comprehrasive
ollow up Actions/ACJ, Mental Health Behavioral m^^.
lth Child) Available CONTAINS Medicaid/Medipass Card
Detention Order " MEDICAL Physician.
lard Copies ofSocial Security Card Birth Certificate Case Plans Judicial Review Social Study Reports
tel Day Care
/ Last Seen by Doctor Hearing FSPT_
/ / /
Dental, Vision /
Annual Physical l_ I I
I
m •- Case Manager
LVAglgNS ^ l ^ ^ ^ ^ ^ A J J j ^ ^ -
DevelopmentaI_ Last Visit /
WA/df^'^,^Y01A6'. ^NT/SHEL': /SHELTERmELiU:nTE/SpHQpL/PROVIDERC^^
^^niJ '&^n rrJ/f/'-^7r^r}c{A COMMENTS ^
/4^e^K n^c^'cm^-^AAJM^ mA OGRESSyTOWAI
la-xXhA/Yi^L m NEX
= ^
9. EQIXOWUPZRIICOMMENDAIIONS for NEXT VISIT . S AADPkryiYl Cfc:77. Y—AC ~
10. FAMILY VISITATION Parents JSERVATIONS
Sibling Therapeutic, Dates
date
COUNSELOR - PI/PS/FC SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY - CASE FDLE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
r y ^ '
Center ftr liamily & ^ I d Enrictiment, Inc VISITATION REPORT SUMMARY
\ _ / Date Placed
/ DATE of VISIT 0 9 - , ] A U l o t NEXT COURT DATE <>Z/ / h V NAME of Child DOB I I ^ NAME/ADDRESS OF PLACEMENT
^
NNOUNC
Sufficient Food V/>o
fajrCAJ:: ZIP CODE
R^rii/iiH^OHrC^f&TCnSma 1977
PLACEMENT y^ Foster Home
Shelter Residential Facility Group Home
^Relative VISIT: ANNOUNCED UNANNOUNCED \/_ Other NAME of COUNSELOR'Yv^ ^Ou^eirLr^ TEhl/^3-<^3DS U N I T g ^
Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION In the CASE NARRATIVE. 1. CONDITION OF HOME ^ Acceptable WuyQ Environment Safe for Child / - ^ DESCRIBE f a , m i h / / 'u^^ t/y^ oC H^i^eA.
Relationship Ffd&r
Toy's/Play area y-QO ESCRIB]^ f C l m i h j JlO^i^ uy^ (K- fh.ir^^ AMypPyyi- hnyyiY JY? ^ t A / ^ t j J & h ^ ^ ' f l D n \ fAhv^i. /-( Yk /i('^y}.uo..yJ.pUrxJ>tjUL&fDy AcfAJ. MjyjOY. A/io S ^ M A / V ^ / - ' / / I / ; V .
[as the number of occupants in the home changed? Yes sZ No Haff )ccupants J changed? If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name . DOB . SS#
^ ± 2. CONDITION of CHILD Healthv TU/Q Well Nourished_^60__ Placement Appropriate jJI/i Signs o buse
OfT
Behavior•^/'4A1<1^ )fl)li^U.] f ^pp^amA' t ' ^d ' cCeH^U IJW^JU W ' HOTLINE/LICENSING ndtified ~AA0C
OBSERVATIONS ofCHILD } i JYL A^/ '^AiuJ:^ fik^S^iCtjC Cnt/A'AAtr>i • J ^ C A
3. SERVICES NEEDED Name: School Center
Health Care: Medical K)0Immimizations ;do Dental AI0 Hearing AJO Vision AJP Counseling/Therapy K3Q Clothing tJQ Tutoring ^ J Q
Grade/"^^ DayCare jAj)
. Mental Health AJQ CMS tJX) SSI KAQ . jJO Parenting Classes Therapeutic Visitation
Developmental: Early Intervention (0-5) A/O Substance Abuse Newbom 0 FDLRS trjQ FSPT tAO CRC Alii Independent Living: Assessment j yQ Curriculum ^ ^ j Plan hJO Pregnancy Services jj/Q 16+ f jQ DJJ /t/Q Economic Services /JO Relative Caregiver YdO Housing A/D Vocational A/Q Domestic Violence IJO Exit Interviews ^ ( P Assessments: ComprehensiveAIO Mental H^altl^O BejiavioralA/p Substance Abuse>y6/ Academic / Q Developmental AJQ
JytC Follow up Actions, _fhi_ :al HealthA^O Beha
,^-14A/IA>OO y?./yyi/y>
4. CLIENT RESOURCE RECORD CONTAINS Medicaid/Medipass Card
Detention Order Case Plans_ MEDICAL Phvsician
(Blue Book Stays with Child) Available'y./Lg Current VU Reviewed ^^_^ i yjLo Copies ofSocial Security Card h/V Birth Certificate AAO
Judicial Review Social Study Reports tel
Day Care / /
Last Seen by Doctor (31 Hearing / / FSPT y j Q
JCM. _ Dental, Vision / /
5. COUNSELOR O B S E R V A T I p N S _ _ ^ _ _ Yrui/)J:: A A <La.jY OAJ J Y l u Y k / r / j ^
Developmental,
Annual Physical , , • Last Visit / ? y : / / y ^ / - d ^ M
, Case Manager JJ f A ~ tel / J ] A f-thVYl-f IS> r'A^O/L; YI^AAT AJU^AL I tCai lc t^A- t€%,.t)t)rtYVl.-
6. FOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDER COMMENTS
y ~ i ^ ~ I S S U E S re: SERVICES C O a ^ ^ ^ t / ^ CJ/VM^AAAU.5 h> VLpirCiS '^Y-C/\jf' tmufj^A.ruCi guuCCtA
7. CHILD'S COMMENTS / • (/
8. PROGRESS TOWARDS GOAL M . / l ^ y U YXpp^a^iihZ. f i ' n a , / O U d a y y i i ^
9. FOLLOW UP/RECOMMEJVDATIONS for NEXT VISIT
10. FAMILY VISITATION Parents, )BSERVATIONS
Sibling, Therapeutic,
~ J ^ / C 'Je>c^£
Signature date
Dates
/ ^ Sigr^mre / date y ^ Signattire / date
COUNSELOR - PI/PS/FC SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PESIK COPY - CAREGIVER/PROVIDER
"^iS®
Center for FamilyS ^ildFnrifhmpntlnf.
PLACEMENT y>C- Foster Home
Shelter
S.eA idMf.
II'M^
I
f^lryi' HI VISITATION REPORT SUMMARY
__/ Date Placed
DATEofVISIT NAMEofChild
0 ^ NEXT COURT DATE "^ D
ItQy
, Residential Facility , Group Home Relative Other
^ ^ ^ f e ZIP CODE
Relationship yroSp y fL> f a r t y u t / T VISIT; ANNpU]<?CED. UNANNOUNCED ^
NAME of COUNSELOR y v ^ FrZULa^rtyo TELVf ] 'V3/>I UNIT^P^ Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION In the CASE NARRATIVE. 1. CONDITION OF H O M E Acceptable /AJd Environment Safe for Child j^u^^ Sufficient ] D E S C R I B E / ^ ;>)<?> ^ / . i ^ m r e ^ c c / i T r z i j C n A o h ^ ^ h i
f v i f ^ ktrmJ-of occupants in the home changed? Yes
AYyyi i^uy
Has the number of occupants \C No If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name , DOB , SS# .
^ — - H i ± 2. CONDITION of CHILD ^ Healthv ^ J / > Well Nourished Y L Q Placement Appropriate 7L6.O Signs ofNeglect/Abuse
iOBSERVATIONS of CHILD AAu^hlYL / C
Behavior f / j ^ j y ^ U ] f b Y i U ] (^C^flJiJ^l/.] CO^IJ'TYhSLn. A/lYyJU g > HOTLINg/LICENSING notified ^ [ A l
' lUaX
3. SERVICES NEE Grade / * Day Care / J d Neighborhood CenteHealth Care: MedicaU.^ Immunizations AA? Dental AA) Hearing A ^ P Visioryjp Mental Health AJQ CMS /AJ SSI W Counseling/Therapy /VQ Clothing KAO Tutoring AJO Parenting Classes Therapeutic Visitation /QQ Developmental: Early Intervention (0-5) A J O Substance Abuse Newbom / j Q FDLRS AJQ FSPT A/V CRC A J Q Independent Living: Assessment /l/Q Curriculum AYO Plan kAiO Pregnancy Services A J \ J 16+ / J Q DJJ A/O Economic Services hJQ Relative Caregiver fjQ Housing j J O Vocational AJQ Domestic Violence A / 0 Exit Interviews Mt? Assessments: Comprehensive fjQ Mental Healthit>(? Behavioral UO Substance Abuse A^O Academic AJO Developmental /{/p Follow up Actions, /l/l9
y u ^ 4. CLIENT RESOURCE RECORD (Blue Book stays with Child) Available y.cQ Current V .^^ Reviewed )C CONTAINS Medicaid/Medipass Card ^-LQ Copies ofSocial Security Card x / O Birth Certificate / J g
Detention Order Case Plans Judicial Review Social Study Reports; Day Care MEDICAL Phvsician tel Annual Physical I I ,
Last Seen by Doctor D / / tJY Dental Last Visit /USJ p ^^Jo-A- O'B/CiS Hearing I I Vision / / ^Developmental ^ FSPT / J D CaseManager W / 4 ~ . ^ ^ A J j y ^
5. COUNSELOROBSERVATIONS / ^ r ~^y7iJit/>t^ LJA^ A O - ^ J . -U; j HtTT'Ak^/JHYH. . / - { / ruy i^
/ l U r { t u i 6. FOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDER COMMENTS
t ISSUES re: SERVICES ^ . y ^ / / . , . U/vMvu^^ /•p'&^/Oi-^M ^ i ^ i ^ . ^ . ^ /.^. ^ l ] ^ j 4 a J j W QyjA eUU^/y. i ^ ^ P^^'r^^i / . i — , , ^
7. CHILD'S COMMEIVTS Clr • A. k-LMyl H.Ajh S A J - U / M C J U yj^fp^
8. PROGRESS TOWARDS GOAL jhOi^L-L/i i s a^^Y)i^/iAfr fCY)A I c/udevyHYA^
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
P kO. FAMILY VISITATION Parents SERVATIONS
. Sibling, Therapeutic,
Signature date
Dates
iCY'X ? M - / . y C ^ cQ-J/kAji- 7ACCCAYA<A o^AitA^ A Sisnatwe / date / Sienature/^ date Signature / date
COUNSELOR - PI/PS/FC
^y date
SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
c Center for Family §
Cfiild Enricliment, Inc /;er«/ji«fl our c/;il()ren Sirice 1977
. LACEMENT ^ ^ ^ Foster Home
/ _ / _ Date Placed
, Shelter , Residential Facility , Group Home Relative Other
V I S I T A T I O N R E P O R T S U M M A R Y
DATE of VISIT ^ / / ^ ( ^ A 9 - NEXT COURT DATE NAME of Child / U u J o ^ i ^ "T ) fU>tm DOB g " 1 2 ^ QD
SsM~/^A/ t / ' ) ! ryJne>^ IP CODE
Relationship _ VISIT
/==^A^Hr A^YLYLeyy^::^ ANNOUNCED - . ^ U N A N N O U N C E D
NAME of COUNSELOR fignJ^^^A^ ThJlYXL. T E I ^ £ ) ^ ^ % U N I T ^ ^ rihe status. FXPTAIN ORSF.RVATTONS/TNFORM ATION in the TA.SF. NAPR ATTVF ' Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION In the CASE NARRATIVE,'
1. CONDITION OF H O M E <^iYI(?^ Acceptable '''l/KLo Environment Safe for Child .„ A ^ ^ ^ DESCRIBE '
JLU
Sufficient Food
•)<: .aAn o,e_j ',^WAPr^'r .A^oyy-\AL^ ^ / ^ D
Toys/Play area
Has-the number of occupaiits in the home changed?
r , ^ ^ 7 ¥ A P y ^ r ^ .Y ' \ ^^Yy- \ iL^ y C ^ J r j - ^ . Y ^ H D ^ Y f ^ ^ ' U . a S ^ ^ J Y - ^ ^ yA^^a . O / . ^ J A ' Y Y M J ^ - ^ YkUYe /f^J~^^io^. ^Af^<p^./b the home changed? Yes No s ^ ^ f l > / ^ ^ y \ ^ A , ^ 'Op / ^S .x t ^^ i
If so, please list the name, date of birth and social security number of the new occupant(s). If the new^ccupant is another foster child, please omit. Name DOB SS#
2. CONDITI Healthy Placement Appropriate OBSERVATIONS of
^4^(Ar\ ^^^rJ)
Nof CHILD Well Nourished
SiIL
Behavior, Abuse /V)0 ,^<^4A-^H0TLrt<[b/LICdNSING"nc
M ^ , HOTLINE/LICBNSING notified
i^\y\A-CAy-] I I
4 U ^ <L. hji_aSl v>^l g^S^
^i^cUJ nf^'o^JCA^cf 'Qf\ a ^ ^ _ . ^ jd^YV
&iQ DayCare 3. SERVICES NEEDED Narpe: Neighborhood Center Health Care: Medical Counseling/Therapy
Follow up Actions
Current 4. CLIENT RESOURCE RECORD (Blue Book Stays with Child) Available_ CONTAINS Medicaid/Medipass Card Copies ofSocial Security Card,
Detention Order ^-Case Plans Judieial Review Social Study Reports
Reviewed Birth Certificate
MEDICAL Phvsicia - Last Seen by Doctor_ Hearing / / FSPT
Dental, Vision / / Developmental,
Day Care Annual Physical
Last Visit
Case Manager 5. COUNSELOR OBSERVATIONS / O U A ^ c ^ ^ /yi-^cfC^JP.
tYi/Yul ^ ^ r Z R i y ^ T Y ^ y ^ ^ - A A . AriY-Y^j:r^/YAi.
, tel
6. FOSTER BARENT/SEEELTER/RELATIVE/SCHOOL/PROVmER COMMENTS . ^ j Y l 5BEELTER/
^/^A<»-®-(^_ H - ^ Q _ M ^ ^ ^ Q ^ A . ' / l ^ ^ ^ A r r - ' f Y ^ O u A U i . , fL.0A\^J<^LAO^(A ^ ^ ISSUE ' ' ^ ISSUES re: SERVICES ^ / - v ^
^•4^WQ . "rks. -fjD h
L& o_dUY^- .. Q<rJr^9C:p) L
Ary^rA.^ 7. CHILD'S COMMENTS . ^ o j g j f e ^ o
3
8. PROGRESS TOWARDS GOAL \Y9oJfSC >(TV->
9. F O L L O W UP/RECOMMENDATIONS for NEXT VISIT
10. FAMILY VISITATION Parents, OBSERVATIONS
Sibling, Therapeutic, Dates
i/fjM Signatiure Signatiue date
COUNSELOR - PI/PS/FC
Signature ' / date
SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY - CASE FDLE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVDDER
^s=gS^
Center for FamilyS Child Enridiment, lnc
l^triiltinq our C^foren Since T577
?LAi:EMENT Foster Home Shelter Residential Facility Group Home
Relative Other
/ _ / Date Placed
VISITATION REPORT SUMMARY
DATE of VISIT 0 } m ( y 6 ^ _ NEXT COURT DATE NAME of Child pORNAME/ADDRESS OF PLACEMENT C ^ U T n e Y ^ J^^/Z.lqjTYnY%-^
ZIP CODE F^as^^J haVY\^
VISIT: ANNOUNCED v/'UNANNOUNCED Relationship
NAME of C O U N S E L O R / ^ ^ 1 ^ / V ^ TTilUtC^ T E t 3 ^ ) i//AY/m UNIT ^ U le status. EXPLAIN ORSFRVATION.S/TNFORMATION in thfi CA.SE NARRATIVE / Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE.
1. CONDITION p F HOME Acceptable ^ f S . Environment Safe for Child lAS^ a Sufficient Food 2JS3<3 Toys/Play area D E S C R I B E ^ P / ? ^ . ^ . ./Ayy^Y-eA-yOWYT^yP^yrb^ ^yY) C J " ^ ^ ^ ^ ^ ^ - ^ ^ L-'^-
.^.^^£u^ 'A^,^AMr)AaCUA( /y0iry)Y> ^^.^AZAZZn^a^ ^//-(TYAp.^. ^^n ^^^^^^-p-l .^^f^ '^^^C^ ^LYiy)^COy\J^^C^ . CUAuiCAYfy)j>^^ -f ,Y iCn ^ ^ C A ^ - ^ Cy^ < j L ^ y , J ^ t^-C-Ac^ ^s the number of occupants in the home changed? Yes No ^ (CY
If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name DOB SS#
2. CONDITION of CHILD Healthv ""^j}/) WellNourished JK/A) Behavior Placement Ar ropriate ^^/^t^igQS_ofNe^ct/Abuse / l / ^ e4cjPt<t 05SERVATI0NS o f ' ^ ' " '^ " ^ - ^ ^ «.x) L/ . . V^o
Ml ^LD / A ^ . • c( ^AJY^LC^
rC UAYU^ (CAOu>Q>Cu2s_. HOTLINE^CENSING notified
QL
3. SERVICES NEEDED Name: School Grade:2g^Day Care" Neighborhood Center , / O /7Af~ ., y J Health Care: Medical/y^ Immunizations Counseling/Therapy Developmental: Early Intervention Independent Living: Assessmerit Economic Services .ReJatiSje Cargiver Assessments: Comprehen^iv^/j^^flMenfal Health FollowupActions ^ ^
" •- Current 4. CLIENT RESOURCE RECORD (Blue Book Stays with Child) Available_ CONTAINS Medicaid/Medipass Card Copies ofSocial Security Card
Detention Order ^^ Case Plans_ ^ judicial Review Social Study Reports MEDICAL
Reviewed Birth Certificate
tention Order Case Plans_^ Judicial Revie .Phvsiciai . Q\ Last Seen by Doctor QT"/-—- / 0'~7^ental
Day Care Aimual Physicalj^^
Last Visit / Hearing FSPT
/ / Vision / / Developmental,
5. COUNSELOR OBSERVATIONS J l^O
A^^n/t^ n>^f€u^ ^nr^jpTp^
Case Manager ^ tel
^ 7fe 5_E
A ^ ^
ISSUES re: SEB^VICES ^ Q ^ P A C U ^ ^ - W _ < ? y A <7 CA^ . . o . - y ^ / i
7. CHILD'S COMMENTS
8. PROGRESS TOWARDS GOAL Cl(j/Q^f-^Chc^Pyn /A^^^(CX_ > ^ 0CA_- y^A^(^^s2z^ q J
[ONS for NEXT VISIT ( A ' l (J ^ 9. FOLLOW UP/RECOMMENDATIONS
10. FAMILY VISITATION Parents OBSERVATIONS
Sibling Therapeutic, Dates
Signature date Sighature date
COUNSELOR - PI/PS/FC
Signatufe '' jJate
SUPERVISORY REVIEW
^Jf//i)jf
CAREGIVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
t
lAente r forWyg )\] Child Enrictiment, Inc
•ri-Jjiiti our cfnf&rcH Since Km
-ACEMENT
Foster Home Shelter Residential Group Home Relative Other
C^^^ 7
/ / Date Placed
VISITATION REPORT SUMMARY
DATE of VISIT t ^ " ^ ' Y " ^ / N E X T COURT DATE NAME of CHILD h4 U P , / ^ ^ r - ^ C T T o r2_ DOB ^ 2 ^ Q Q _ NAME/ADDRESS ofPLACEMENT
Relationship pC>g?7"fe^ ^ Q - T - ^ A ^ j ^
VISIT: ANNOUNCED UNANNOUNCED NAME OfCOUNSELOR L - Q - f < l - < ' + - l U r a / ? / ^ E L i ^ y / V y ' A Q ' ^ U N I T 7 7 < 1 / '
Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE. ' \ . CONDITIONofHOME / , Acceptable y ^ Environment Safe for Child"y- " ^ Sufficient Food Y ' ^ Toys/Play a reaf^^- j^ Total number ofchildren in home Ages ^ Siblings DESCRIBE C S U , . ^ g \ Vj^ rsJg .^ ^ e ^ e ^ u > \ \ ^ ' ~ \ i ^ - - ^ U ^ »xi>v-^_ r ^ J ^ Aaa^^trf-^CTi:
<- '~ - ' ^^"~^V-t:.- Ujg>vv..--ft. X. S ~ Cl'C^>.><^ ' ^•sw ^ <-A.JC? g » v ^ \ ^ ^ C <svtgitu:^.a-T4
2. CONDITTON ofCHILD -Ls^-±Sv
Healthy Well Nourished Behavior tJ i . (^; Placement Appropriate
OBSERVATIOPfS, of CHILD CX^_ Signs ofNeglect/ Abuse_
\za gJU^^M^ > <ry^ e^-3-a»r-»—• FAHIS/LICENSING notifi? If^ 1—
.•V-w<"' -IJ
3. SERVICES NEEDED Name: School Health Care: Medical Immunizations Counseling/Therapy
Day Care_ Dental Hearing ; Vision.
Clothing _ Tutoring Developmental: Early Intervention (0-5) Independent Living: Assessment Curriculum Economic Services
Substance Abuse Newbom Parenting Classes
FDLRS
Neighborhood Center . Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
Plan Pregnancy Services 16-1-Relative Caregiver Housing Vocational Domestic Violence
Pssessments: Comprehensive_ ollow up Actions
Mental Health Behavioral Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical
Dental FSPT
Current Reviewed . & Birth Certificate _
Day Care tel
Last Visit / / / / Last seen by Doctor / /
Hearing Vision Developmental FSPT ^Case Manager tel .
5. COUNSELOROBSERVATIONS ( l \ j . ^ \ A v/ 'H c ^ <3-pa p o a p i-[<:<JkLV c ^ oA-g--€-S_S> < ^ ^ ^ ^ \ ^ ^ V^^Q-^^^-O o ^ C - ^ c ^ A x V - ^ ^ ' C _ A i . g r \ t v x v ,>^ \ JdAcJu . lS 7 ~ r ; ? L a ^ i -
6. FOSTER PARE E^T/Smm'ER/RELATIVE/SCHOOL/PRpVIPER COMMENTS VU^_ X s ; e . / W j ^ O c ^ f N i
^ ISSUES re: SERVICES
7. CHILD'SCOMMENTS CXi->>Jl«sX , ^ ' = ° ^ - ^ ' ^ l ^ ^ ^ l ^ VS ^ l » - ^ ^^-^^^<^ \ . . y i r \ f>f y*~Jt
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
[). FAMILY VISITATION Parents )BSERVATI6NS ^
Siblings Therapeutic_
^ i^ I i l~ j ^^ i^^^r7 Signature date ,, . .^j.-.-. : j Signature date ' \^ ig t^ j i / j ' e^ '^ NJ ate s^ j
CAREGIVER/OTriER f^r .-.; COUNSELOR - PI/PS/FC SUPERVISORYREVIEW nowledgement only that Counslilof visited ••-K
WHITE COPY-G-ASE FILE • YEUliOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
^^*<s— n - : ^ <5S-
Jf^ M/i /I
Center for liamily § Child Enrichment, Inc.
cfcni&iittruHrctrifiJreti^iHcciOT
RLACEMENT Foster Home
. Shelter
. Residential Group Home Relative Other
VISITATION REPORT SUMMARY
/ / Date Placed NAME OfCHILD DOB
DATEofVISIT NEXT COURT DATE
NAME/APPRESS of PLACEMENT CA-OiVVX S T J A T ) r o - ^ b t v t g
Relationship - j rOg^tg^r- l iAO-ft^-e^i^ VISIT: ANNOUNCED _ UNANNOUNCED
ZIP CODE
NAME OfCOUNSELOR Lq-j -€ .e- i^ J ^ j m i ^ / z t f T E L ^ ' y ? - ^ ' ? ^ ? UNIT 7 7 ^ status. EXPLAIN OBSERVATIONS/INFORMATION in the CA.SE NARRATIVE. / Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION iri the CASE NARRATIVE,
1. CONDITIONofHOME Acceptable J " ^ Environment Safe for Child ' ^ ^ J ^ Sufficient Food y g ^ Toys/Play area ^ ^ ^ Total number ofchildren in hcune Ages Siblings B DESCRIBE C X ^ ^ ^ ^ A . <^A.gy-a^ g ^ . ^ * : - . . ^ \ u^ •d.o>-.e_ ^ O t v->«~ft ^^K^^-y-JiX .
(TJO
^ t . ^_^>. -
2. CONDII Healthy
ON OfCHILD Well Nourished Behavior
Placement Appropriate OBSERVATIONS OfCHILD BSERVAl
^
Signs ofNeglect/ Abuse_ ^ |Q•r id .A.JeKJ| b<gX^Ugt.^^V
= ^ s = -a:! . q FAHIS/LICENSING notified
K-g f <-. -A_^aJL/t g l e i g j J ^ t - ^ -^^ -^e . x> r~ t ^ v »
3. SERVICES NEEDED Name: School _ Health Care: Medical Immunizations CounseHng/Therapy
Day Care_ Dental
Clothing. Hearing Vision
Tutoring _ Pevelopmental: Early Intervention (0-5) Independent Living: Assessment Curriculum Economic Services
Parenting Classes FDLRS Substance Abuse Newborn _
Plan Pregnancy Services
Neighborhood Center Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
16+ DJJ
, ^ ^ S ' . m Relative Caregiver Housing Vocational Domestic Violence
Assessments: Comprehensive_ llow up Actions
Mental Health Behavioral Substance Abuse Academic _Exit Interviews _ _ DevelopmentaI_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available. Current Reviewed CONTAINS Medicaid/Medipass Card
Detention Order Case Plans Copies ofSocial Security Card . & Birth Certificate
Day Care MEDICAL Physician
Dental FSPT
Judicial Review Social Study Reports Annual Physical / / Last seen by Doctor
Last Visit / / Hearing Vision Developmental tel / /
5. COUNSELOR OBSERVATIONS r St.. . \ J ^ Case Manager _
-P <3-fr7 p> ^ . t t \ K i ^AfnT ^ A i cJLi-TagJj^^
6. JFOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDER COMMENTS t / U g -^-is»SKrV-4a_r * f
ISSUES re: SERVICES
7. CHILD'SCOMMENTS C ]U-x>A.A. < ^ « s s _ ^ ^ v.:^C->-^°^-.^ ^ ^
la. ^.L^ 3 r / "<-?s^
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENPATIONS for NEXT VISIT
kp. FAMILY VISITATION Parents. (OBSERVATIONS
_ Siblings Therapeutic_
Sigd^ture date :AREGIVERyOTHER
Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
Signature date COUNSELOR - PI/PS/FC
nature " date SUPERVISORY REVIEW
ii Center for Family S
Child Enrichment, Inc
? cT ^ ^ ^ - ^ n/u
c/jtryiirtij oil r c/;ifttrCM bJMCC 1977
LACEMENT _ Foster Home _ Shelter _ Residential _Group Home _ Relative
Other
Date Placed
V I S I T A T I O N R E P O R T S U M M A R Y
PATE OfVISIT M- I ^ i ^ J NEXT COURT PATE NAME of CHILP N U fel A H f J C T O ^ POB . 5 ^ / 2 ^ CSO NAME/APPRESS ofPLACEMENT C A i ^ M ^ J ^
ZIP CODE Relationship ^ O ^ a l k j C ^ M O - H ^ J a - ^
VISIT: ANNOUNCED UNANNOUNCED NAME of COUNSELOR L c i - h c ^ - f Ih^AXltvC^IS.h^fZ-I^XCi'l UNIT 7 7 C^
Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE! ' 1. CONDITIONofHOME Acceptable Environment Safe for Child Total number ofchildren in home Ages PESCRIBE C I A ^ ^ A U j - e < - ^ 9 ^ e ^ ^ , 4 - A ^
^ rv*-T7'»a 1 - T l n n _ i i a n : g - O - g - ^ j ^
Sufficient Food _ Siblings
_ Toys/Play area _
^ a\^^^A
Lt-^fi i y \ ^ : ^
\ ^ \ / s ^ s»^ J ^ £ <?.rf>gL.r"
O { •e^ou.^
2. CONPITION of CHILP Healthy Well Nourished Placement Appropriate
k •Behavior
OBSERVATIONS of CHILP Signs of Neglect/ Abuse
-A_
^ 4-gsneaAjA mf 4-^& ka -e..
. FAHIS/L
r:f--^aw^ ? t f « . - r ^ . :E: CENSING notified / /
vfli^
vidEsri g^3>-^<^'*-€>>g^ Ci. t x < - j £
« ^ 3. SERVICES'NEEPEP Name: School 'O Grade Pay Care Neighborhood Center. Health Care: Medical Immunizations Dental Hearing Vision Mental Health CMS SSI_ Counseling/Therapy Clothing Tutoring Parenting Classes
FDLRS Developmental: Early Intervention (0-5) Substance Abuse Newborn _ Independent Living: Assessment Curriculum Plan Pregnancy Services Economic Services
Therapeutic Visitation FSPT CRC
16+
m Relative Caregiver
Assessments: Comprehensive_ lollow up Actions
Mental Health Housing
Behavioral Vocational Domestic Violence
Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports tel Annual Physical / /
Last Visit _ _ / _ _ / Hearing
Current Reviewed
MEDICAL Physician Dental
. & Birth Certificate Day Care
Last seen by Doctor / / Vision Developmental
FSPT Case Manager 5. COmSELOR OBSERVATIONS C > U ^ < a X
tel
r ^^^^T^ '-"'—^ - s ^ : ^ ==- sJ ^
6. FOSTER PARE^T/SlgEI^TER/RELATIVE/SCHOOL/PROVIDER COMMENTS \ \ A J ^ <S^rsP=^J^ i^ ' ^ '^^^^^ <- « - - ^ gS^yCc^^-^i
'p'<tfL^ ''<tfL^>F'^, ^
ISSUES re: SERVICES
7. CHILD'SCOMMENTS g ? L > i ^ <s; , . s>_^ g >.^.>Cc->.><^"y- ^ <->Mg j 3 , < 3 ^ \ "-"^-^-t ^ ^ ^
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
Inature date'' ' ' ' Signature CAREGIVER/OTHER COUNSELOR - PI/PS/FC
Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
SUPERVISORY REVIEW
^ ^ *ES>
Center for fiamily & Child Enrichment, lnc
Mt^^ft t 'ulyi ty OHT dfllHrctt Since [977
^ ^ L A C E M E N T Foster Home Shelter Residential
jGroup Home Relative Other
Date Placed
Relationship VISIT
NAME of Complete blanks with yes or no and describe status. EXPLAIN 1. C O N D I T I O N o f H O M E Acceptable Environment Safe for Child _
Ages
V I S I T A T I O N R E P O R T S U M M A R Y
PATE ofVISIT J 3 I 7 l ^ ' W ^ NEXT COURT PATE NAME of CHILP ' P ONAME/APPRESS ofPLACEMENT CL.A^n/t'&r<JI
ZIP CODE ^r-..<T&(L MO-^fN-eTt. ANNOUNCED UNANNOUNCED
COUNSELOR L A T £ i = f^(f^JZMtlKTEL i / f^• i f . -Z .Q^ UNIT 7 7 ^ XPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE. '
Total number ofchildren in ho DESCRIBE
Sufficient Food Siblings _
Toys/Play area
Jr c.4'e < s a . ^ c A , ^ _
2. C O N P I T I O N of C H I L P Healthy WellNourished Behavior
^ Placement Appropriate Signs ofNeglect/ Abuse OBSERVATIONS of C H I L P Q X ^ ^ i J V
VU3 VA J u r ^ . J S - A ^ \ *::?
1 ^ n J r ^ W» ^ - . X > < ^
k± «^-- igS«>-=^
•AHIS/LICENSING notified / /
_^5U ^
3. SERVICES N E E P E D Name: School _ Health C a r e : Medical Immunizations Counseling/Therapy
Grade Day Care_ Dental Hearing Vision
Clothing. Tutoring Parenting Classes FDLRS Pevelopmental : Early Intervention (0-5) Substance Abuse Newborn
Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ conomic Services
Neighborhood Center . Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
Relative Caregiver isessments: Comprehensive_
Follow up Actions Mental Health
Housing Behavioral
Vocational Domestic Violence Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
4. CLIENT R E S O U R C E R E C O R D (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel AnnualPhysical / /
Dental Last Visit __!__!_ FSPT
5. C O U N S E L O R O B S E R V A T I O N S
Current Reviewed _ & Birth Certificate.
Day Care
Hearing Last seen by Doctor / /
Vision Developmental tel Case Manager ji tei _^_^ \
: ^ i U-^^ 6. F Q S T E R PA&ENT/SHELTER/RELATIVE/SCHOOL/PROVIDER C O M M E N T S r V g b g ~ ^ r 4 - « . y ~ v:af3W._A--€^ ^ t j J t ^
^ ISSUES re : SERVICES
7. C H I L D ' S C O M M E N T S < r _ ( U . ^ 3 « A
8. P R O G R E S S T O W A R D S G O A L
9. F O L L O W U P / R E C O M M E N P A T I O N S for NEXT VISIT
10. FAMILY VISITATION Parents OBSERVATIONS
^ ^ 9 ^ Therapeutic_ Dates
j^v~ xj-} \t>l ^Z2=Z. -7=^^ ^ ^ ? ^ gfiamre date
C A R E G I V E R / O T H E R Acknowledgement only that Counselor visited
Signature date COUNSELOR - PI/PS/FC
Signature date SUPERVISORY R E V I E W
WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
Center for FamilyS Child Enrichment, Inc.
^fl |hC^rt .</; iKj) OH r c/ ifdrCH SIHCC 1977
^ P L A C E M E N T Foster Home Shelter Residential Group Home Relative Other
L^
? - f i
/ / Date Placed
V I S I T A T I O N R E P O R T S U M M A R Y
DATE of VISIT S - j i I C J ^ B -NAME of CHILD. p O c r T b g - i ^ ii ^ NAME/APPRESS of PLACEMENT C-Ag-ZW £ A /
Relationship ^ ! ^ / " ^ 7 g - p f i ; ^ ^ ; l ^ )
NEXT COURT PATE DOB /^i2£,l O a
ZIP C O D E j Z ^ i / ^
VISIT: ANNOUN^^D ^UNANNOUNCED
Complete blanks with yes or no and describe L CONDITIONofHOME Acceptable y - e - ^ Environment Safe for Child ^ - g ^ Total number ofchildren in l\ome Ages DESCRIBE O ^ ^ A v > ^ g = ^ - ^ e c s u ^
NAME of COUNSELOR L / t / £ f e F I fe£AfkHYTELZiLy.T-<A7^"? UNIT 7 7 JJ-status. EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE.
Sufficient Food Siblings
Toys/Play area
.po x^e, * ^
2. CONDITIONofCHILD Healthy WellNourished Behavior PlacementAppropriate Signs ofNeglect/Abuse OBSERVATIONS of CHILD C K J L ^ \ < ^
N V Q \ VA cX/t C ^ j i h y v " F A H I ^
EPBID Name: School
^buse jsJ^G \ v/y cA>t C ^ j H y V " FAHIS/LICENSING notified / /
JS_ v/^^J2—•
3. SERVICES N E Health Care: Medical Counseling/Therapy _
Grade Day Care_ Immunizations Dental
Clothing. , Hearing Vision
Tutoring Parenting Classes FDLRS Developmental: Early Intervention (0-5) Substance Abuse Newborn
Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ _ conomic Services Relative Caregiver Housing Vocational Domestic Violence
Neighborhood Center Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
ssessments: Comprehensive_ Follow up Actions
Mental Health Behavioral Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
Current Reviewed & Birth Certificate.
Day Care Last seen by Doctor
Developmental
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical / /
Dental Last Visit / / Hearing Vision FSPT Case Manager tel fl A
5. COUNSELOR OBSERVATIONS C-X<_.J^ <aX u*3 o ^ B ~ ^T^^L-^t—-alfl/S c»-te? f=> Q 3 p f " ( «< ' i h O L c j
COMMENTS \ \ , . J t _ ^ - Q S ^ ^ Z J ^ . p T j ^ - T ^ . ^ , ^ ^ 6, FOSTERJPARENT/SHELTER/RELATIVE/SCHOOL/PROVIDER
ISSUES re: SERVICES :S3 ^ i
7. CHILD'SCOMMENTS C_JU<>^ oK <S--<gg^^'=5. ^-\fi.>~e>»i^ \ ^ < ^ ^ ^
- ^ ^ - Q ,
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
Signature date CAREGIVER/OTHER
Acknowledgement only that Counselor visited
WHITE COPY-CASE FiLE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
i ;v ^ 7 - S
Center for FamilyS Child Enrichment, Inc.
c6eri.'iinijoiirC/;)/()rCHSmcc 1977
i-ACEMENT _ Foster Home _ Shelter _ Residential Group Home
_ Relative Other
/ / Date Placed
VISITATION REPORT SUMMARY
-K\LJiJih M 1 OfPLACEMENT
D A T E o f V I S I T NAME of C H I L P N A M E / A P P R E S S 1
NEXT C O U R T P A T E P O B /
Relat ionship. IJNANNOUNCED
ZIP CODE
VISIT: ANNOUNCED NAME of COUNSELOR I g t j € e J y -
Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION 1. CONDITIONofHOME Acceptable " Y ^ Environment Safe for Child "N/ ^ Sufficient Food " ^ " ^ Toys/Play area Total number ofchildren in home Ages _ J _ I I Z H — Siblings ^ _ _ _ PESCRIBE r J U ^ i o l OL^^^^^g^ J ^ g . g > ^ \ ^ A ^ < . . r . X ^ C ^
iMJEh^JX-qJ^ f UNIT 7 7<^ L T I O N irf t S r c X S E NA'RRATIVE. /
± -saX^ -^^^ t
2. C O N P I T I O N of C H I L P Healthy WellNourished Placement Appropriate
4^ o ^
. . " \ U cA3t C--c»- ft-C^ FAHIL Signs ofNeglect/ Abuse tvJLgT \ U o ^ l r < a » . ^ ~ T r - » ^ FAHIS/LICENSING notified T T
. ^ ; - - gX.^O»^<s3A- kxg V U i-^Lt- C l a j J j - - ^
^ ^ L A - ^ ? s - % . _
Dental Hearing Pay Care_
Vision Neighborhood Center
Mental Health CMS 3."^ERVICES NEEPEP Name: School Health Care: Medical Immunizations Counseling/Therapy Clothing Tutoring Parenting Classes Therapeutic Visitation Developmental: Early Intervention (0-5) Substance Abuse Newbom FDLRS FSPT CRC Independent Living: Assessment Curriculum Plan Economic Services Relative Caregiver Housing Vocational
SSI
Pregnancy Services 16+
^ ^ s jsessments: Comprehensive_ low up Actions
Mental Health Housing
Behavioral Domestic Violence
Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical / /
Dental Last Visit / / Hearing Vision
Current Reviewed , & Birth Certificate _
Day Care Last seen by Doctor / /
Developmental FSPT Case Manager tel
5. COUNSELOR OBSERVATmNS r J U . » J L , « A o ^ - " ^ - g . < ^ e &...y\^ \ ^ > . ; ^ U A ^ ( ' S>Uf<i7J— \ > V J C > ^ «^ \ ^
6. FOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PRO V I P E R C O M M E N T S < r J ^ w ^ A ^ ^ 0.«Mr~-M ^ - g g o t A Vrl QJU.GO»>JLC \ X g - i ^ ^ VA3-t:»Q p
ISSUES re : SERVICES
7. C H I L P ' S C O M M E N T S J. CHILE oA.<-.^<ia>^ -V'gaVQ^ -4^8. '~a_ tOAaQ^u.v.£^ jar"". S?^*-^ ^-^^^
8. PROGRESS TOWARPS GOAL
9. FOLLOW UP/RECOMMENPATIONS for NEXT VISIT
FAMILY VISITATION Parents K S E R V ^ O N S
, Siblings Therapeutic_ Dates
Signature date -AREGIVER/OTHER
" / Acknowledgement only that Counselor visited WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
^/
C4*U£r -for Famiiy atui
ChUd GnnchtHO^ /»te.
fcherUhin^ ourChiUin*^
lACEMENT _ Foster Home _ Shelter _ Residential Group Home
_ Relative Other
<S!-
£-7 ^ 2 -
/ Date Placed
VISITATION REPORT SUMMARY
PATE OfVISIT - ^ ^ ^ - ~ C > 7 NEXT COURT PATE NAME of CHILP POBNAME/APDRESS ofPLACEMENT C/bZLfUgrM
Relationship ^o<-i \^-X~ ZIP CODE
VISIT: ANNOl NAME OfCOUNSELOR
INANNOUNCED [Wy^tJd-
Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION 1. CONDITIONofHOME Acceptable Environment Safe for Child Y " ^ " ^ Total number ofchildren in home PESCRIBE 4 0 - € _ UJQV.A.
Y - ^ Ages 7 - ^
JL
| _
u.. ^
SufficientFood ^blings C -t»-ll _ Sibling
- ^ JXJL
( " ^ ^ Toys/Play area
USSA^C^Z-^T^ UNIT 7 7 S^ ION in the CASE NARRATIVE. /
2. CONPITION of CHILP . f\ i k Healthv ^ < ^ Well Nourished J V ^ j a ^ Behavior H < ^ r ^ K ^ ' - e ^ b e J t c g u J < < r V ^ PlacementAppropriate Signs ofNeglect/Abuse . FAHIS/LICENSING OBSERVATIONS of CHILP (T ' U > J L ' = ^ O - ^ VS , «g .S^W>-~- ^ 4 ^ J o >g « J l ^ L
<^-MA-W5^ y ^ M^£^^L 4^^crf-^~?~- 3fe ified / /
•1 u ^ g t (/• « - < - r ^
I K Q ^ . C a>>Ji^Ja2-S3i-' — <s ^ - ~ _ks_s. 3 3. SERVICES N E E P E P Name: School _ Health Care: Medical Immunizations Counseling/Therapy
Grade Pay Care ^ Dental
Clothing. Hearing Vision
Tutoring Parenting Classes FDLRS Pevelopmental: Early Intervention (0-5) Substance Abuse Newbom
Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ Economic Services
Neighborhood Center , Mental Health CMS
TherapeuticViSitation FSPT CRC
SSI
DJJ Relative Caregiver
Isessments: Comprehensive_
5ilow up Actions Mental Health
Housing Behavioral
Vocational Domestic Violence Substance Abuse Academic
Exit Interviews _ _ Developmental_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical
Dental Last Visit / / Hearing _ FSPT
Current Reviewed . & Birth Certificate _
Day Care / / Last seen by Doctor / /
Vision Developmental Case Manager
5. COUNSELOR OBSERVATIONS v._t-3 x>.>> =>-^^v^ » . ^ y - v — - - T ^ . - V - K - C ^ ^ . ^ , ^ ^ ' . . - ^ -^ 'JloeS!
6. FOSTER PARENT/SHELTEI^^ELATIVE/SCHOOL/PROyiDER COMMENTS T U g . • ^ ^ i S ' ^ J r ^ . J ' ' p Q » i-ISSUES re: SERVICES
ILP'S COMMENTS C J L ^ ^ «J? V..-/'>-ja_ ^ -n
I A - < 2 _ ( ^ « 3 > e ^.A-Cg V - ^ «3^'^Q LA- \ - ^
8. PROGRESS TOWARPS GOAL
9. FOLLOW UP/RECOMMENPATIONS for NEXT VISIT
m. FAMILY VISITATION Parents BSERi^ATIONS
Siblings Therapeutic_ Dates
I Sighature CAREGIVER/OTHER
Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
signature date COUNSELOR - PI/PS/FC
y
V
- g- 5 ^
Center for Family & Child Enrichment, Inc
| B i P L A C E M E N T / / Foster Home
. Shelter Residential Group Home Relative Other
Date Placed
VISITATION REPQRT SUMMARY
DATE ofVISIT ^ / NAME of CHILP N tJ b|<=t ^ p a 7 4 - > s ~ » ^
ACEMENT
NEXT COURT PATE
Relationship VISIT:'
'cS4-t:^i-ANNOUNCED • ii-MAisrMnirMf
ZIP CODE
UNANNOUNCED NAME of COUNSELOR L g L J e e ^ ^ I U r o J ^ f M TEL C J ^ ^ - ^ Z t S S UNIT ' V ? < ^ status. EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE. / Complete blanks with yes or no and describe!
1. CONDITIONofHOME Acceptable ^ ^ ^ Environment Safe for Child ' Y ^ g - ^ Sufficient Food J ' •^^^ Toys/Play area J - ^ Total number of children in home Ages Siblings PESCRIBE O U A A XK'iO.^ # . 1 ^ ^ ^ ^ \ \yy l /Vrpj^p r J ^ - \ ( y ^ J^.<gr4-ev«- \AAn-Xi^-^Lx-
^ 7 A A - W 2. CONBmON of CHILP Healthy Y " ^ WellNourished'^ Placement Appropriate
Behavior
i'lacement Appropriate Signs ot Neglect/ Abuse ^ j |A OBSERVATIONS of O H L P C U ^ J , > p \ G ^ p ^
tdg::^rvvApvQ U-eJAja^A>( c n —
< ^ d ^ t->-w^
FAHIS/LICENSING notified /
e v>«-.^ ' \ -€- _Q_ >.'^< 3. SERVICES N E E P E P Name: School _ Health Care: Medical Immunizations Counseling/Therapy
Grade Pay Care_ Dental
Clothing , Hearing Vision
Tutoring Parentiiig Classes FDLRS Pevelopmental: Early Intervention (0-5) Substance Abuse Newbom
Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ Economic Services
Neighborhood Center Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
Relative Caregiver ^Assessments: Comprehensive_ rFollow up Actions
Mental Health Housing
Behavioral Vocational Domestic Violence
Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
/ /
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical
Dental FSPT_
5. COUNSELOROBSERVATIONS C J ( . ^ \ , A o - ^ ^ J? ^ jr~ ^
Current Reviewed _ & Birth Certificate _
Day Care tel
Last Visit / / Hearing Case Manager
Last seen by Doctor / / Vision Developmental _
^JWyV ^
tel
a DZ v.j»-V. \ A < ? Vo r<»V^A.-er-\ w g ^ -^3»';V<Hf^ ^ ± FOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDEK COMMENTS DERCC
^ ^ — ^ ISSUES re: SERVICES
7. CHILD'S COMMENTS , ^ CJU.yj^ ^r,^A. -U^ .J i ^ - ^ ( . ^ IS> g j - . " ^
t v ^v - t ^ ^ " \ : ^ c . ^ < ^ ^ - 7 ^
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENPATIONS for NEXT VISIT
l tO. FAMILY VISITATION Parents OBSERVATIONi
. Siblings Therapeutic_ Dates
/Sigrfatiu-e date " ' Signature date' Signatun JGIVER/OTHER COUNSELOR - PI/PS/FC SUPERVISORY REVIE
Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
t ^ J - t ^
^
Center for FamilyS Child Enrichment, Inc
lAdJerkfeintj our dnfJWrt since [977
TPLACEMENT _ Foster Home _ Shelter _ Residential Group Home
_ Relative Other
15 7 ? ^
I Date Placed
VISITATION REPORT SUMMARY
DATE of VISIT I ' NAME
f PLACEMENT
Relationship A^z>i^
NEXT COURT PATE
ZIP CODE
VISIT: ANNOUNCED NANNOUNCED NAME of COUNSELOR [ <pL4r.=>J^ |1 7Y-a I f / ^ T E L ^ b y e - ^ ? / : ) JL UNIT 1'?<J^ status. EXPLAIN OBSERVATIONS/INFORMATION in tht CASENARRATIVE. / Complete blanks with yes or no and describe:
1. CONDITIONofHOME Acceptable Y e ^ Environment Safe for Child [ - e ^ Sufficient Food ' Y ^ ^ ^ Toys/Play area ( cSi^
' ' " ' Ages Siblings Total number ofchildren in home DESCRIBE C A/ >\ V eX
^
Behavior 2. CONPITION of CHILP Healthv Y * ^ WellNourished Placement Appropriate Signs of Neg|ect/ Abuse OBSERVATIONS of CHILP C \ A . \ \
4 4 ^ FAHIS/LICENSING notifiei
^BSKKVAiiu s01 cHiLu r AA/\ \ <ax / T . ^ p . « ^ ^ ^ r - ^3y^ k .p .\AV.e_ii rcv^oe . -y-Tor-, E J
3. SERiOCES NEEPEP Name: School Health Care: Medical Immunizations Counseling/Therapy
^ Grade Pay Care_ Dental
Clothing Hearing Vision
Tutoring Substance Abuse Newbom Pevelopmental: Early Intervention (0-5)
Independent Living: Assessment Curriculum Plan Economic Services Relative Caregiver Housing _
Parenting Classes FDLRS
Neighborhood Center . Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
Pregnancy Services 16+ Vocational Domestic Violence
(Assessments: Comprehensive_ Follow up Actions
Mental Health Behavioral Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports Annual Physical
Current Reviewed _ & Birth Certificate
Day Care MEDICAL Physician,
Dental '_ FSPT
tel Last Visit / /
/ / Last seen by Doctor / /
5. COUNSELOROBSERVATIONS C U ^ l o ^ VA ^ o - 3 ^
.^-yaj^l-c-f .P^
Hearing _ Case Manager _
Vision _ Developmental
V > 3 < y - | - ^ ' tel
^ ^
A ^
6.^0STER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDER COMMENTS \ U.-C>, -^^SQ-^-^Lf , "pc ' ^ A<..^-av^ ^ ~A- -« r JU^ ^ o l 1 *^ oAej tL , -^ J^ i ^ jL -^ lAj-^ytU ^-A^-^-^i-^
QX{.t^\ _ ^ - d ^ W^lr-^ 4— W«gL.Aj-< ISSUES re: SERVIC
7. CHILD'SCOMMENTS C i ^ ^ v J i l ? . ^ ^ ^ - y 3 - ^ ^ ^ - ^ '^^ '-g- \ ^ c J ^ t ' ^ ^ / u ^ t ^ ^ - ^
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
lie. FAMILY VISITATION Parents. OBSERVATIONS
Siblings _ Therapeutic
I Sienature
Dates
Signature date :AREGIVER/OTHER
Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
Signature dite COUNSELOR - PI/PS/FC
Signati SUPERVISORY REVIEW
l-lK-6y
#
m
TRANSPORTATION REQUEST FORM
Please provide clear and complete information. If children are goiag to the doctor, please provide MEDICAID # or letter of assurance.
..Whene;yer-pos.SLble, please,submitXRANSRORT-AIION,REQBElSX.AT-LEAST-48 -HOURS in advance to LaBronya Williams, Operations Specialist.
Date request submitted: ' 2-/C/<^(^ CaseManaser. L-A'I € S r l & t f y ^ ^
Cell Phone: -^J^g -31 7 - ^c^^^T ,
Unit Supervisor:AH^JP( U j J | t o ^ ^ Phone -.c^^S' (j 5> " ^ i ^ S
*Case Number: d ^ - J ^ T T^.^^TIS"^ FSW Assigned: CeU Phone:
Child's Name
t^uM J>oc--hr
Race
1^
Sex
P
Age
^
DOB
,^Moo
Social Security
ffl^^JSSTBi^
Medicaid #
* Pertinent information or conaments on child(ren)
TRANSPORTATION NEEDED: (Tlease check all that apply)
f^XOne time Only / ^ / / Q ^ Date of Appointment
Weekly Date of Appointment
One way Transportation Date of Appointment
j / _ R o u n d Trip Transportation .^.JDate of Appointment
l O S P Time
Time
Time
lO/jg^fime
(GOMPi/ETE INFORMATION ON BACK OF TfflS FORM) MUSTANSWER
PICK UP FORM: TAKE TO: Address & Telephone Address & Telephone)
#
Directions: Directions: V
• Returnto: Address & Telephone
Directions for retum: If different firom above
Request accepted
_ Sorry, request cannot be accepted FSW unavailable.
Supervisor Date
* Case Manager: Please note, it is your responsibility to inform all PARTIES INVOLVED of whom will be transporting your child(ren).
#
G ( o • ^
Center for FamilyS Child Enrichment, lnc
•f«rL'/;infloiird;jf(»rcHbiHCCr977
LACEMENT
Foster Home Shelter Residential
^Group Home Relative Other
r H-A
VISITATION REPORT SUMMARY
/ / DATE OfVISIT i l ~ / ( < ^ ~ < ^ < C a Date Placed
^NEXI ^ r T NAME of C H I L P r ^ O L l ^ t q
iME/APPRESSj^f P L A C E M E N T .
T C O U R T P A T E .POB(f2_€^.^L
< • ©^ .^ I^XAyv-Q^w^
Relationsh ZIP CODE
VISIT: A N N O U N C E D c V ^ U N A N N O U N C E D N A M E o f C O U N S E L O R T E L UNIT
Complete blanks with yes or no and describe status. 1. C O N D I T I O N o f H O M E Acceptable Environment Safe for Child Total number of children in home Ages DESCRIBE C U l A o X ^ Q Q ^ - S I . < ^ •
EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE. m^
Sufficient Food Siblings
Toys/Play area
C3_ A V ^
^-'^..-g >« C>— l ^ < ^ Cc-Tr\ fe l A ^ t . t - x * ^ ^ zsAr^ ^^s^=Z.. •> xa-^ig-^ H p S y La «^s-
/3M. Q>^>^J^ 2. C O N D I T I O N o f C H I L D Healthy Well Nourished Placement Appropriate
OBSERVATIONS of CHILD
Behavior M Q Signs ofNeglect/ Abuse " ^
l ^ r - 7 ^ • . ^ c
lar ~i^ jP 'Sr -S~~ /=-^ g .^ jri3^ig,'=^ FAHIS/LICENSIN
^ ^
cs's A^v.ri/ g -IH-^m ai-3. SERVICESNEEDED Name: S c h o o l _ Health Care : Medical Immunizations Counseling/Therapy
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Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ _ Economic Services Relative Caregiver Housing Vocational Domestic Violence
Neighborhood Center . Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
DJJ Exit Interviews
^ ^ ^ s s e s s m e n t s : Comprehensive Mental Health ^PIp!"ollojv up Actions C - A A _ A ^ X O V »^ ^ o ^
KBehavioral Substance Abuse mow up Actions <~-.
eXi,. J^ ^V -*-g_ ^^S l ^^^ Academic ^ Developmental_
J5:5si g>^ -^V~^ s A o ^ ^
4. CLIENT RESOURCE R E C O R D (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical
Dental FSPT
Current Reviewed _ & Birth Certificate
Day Care tel
Last Visit / / / / Last seen by Doctor / /
Hearing Vision Developmental Case Manager _
5. COUNSELOR OBSERVATIONS < ^ ^ J U ^ c»X t A V ^ O L
- ^ ^ f f^P v^g.JH^ l^-^Ds~^^^s-L^^^ji.
R COMMENTS \ w Z . ^^^=>gcJ^-^U-~ ^ g > 0 ^ " ^ - v j : ^ ! ^ 6. EOSTER PARENT/SHELT] RELATIVE/SCHOOL/PROVIDER
^ ^ • ^ ^
ISSUES re : SERVICES
C J U ^ A " ^ 7. C H I L D ' S C O M M E N T S .
i. 8. P R O G R E S S T O W A R D S G O A L
9. F O L L O W UP/RECOMMENPATIONS for NEXT VISIT
JIO. FAMILY VISITATION Parents OBSERVATfQNS
. Siblings _ Therapeutic
njtdoo. \ l i x . f ^ ^ — \\]i4 TUmi Signature date
COUNSELOR - PI/PS/FC date
VISORY REVIEW Ignature a ate
CAREGIVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
T- *^ , - i 3 ^ 5^ -*"
^
Center for Family § Child Enrichment, Inc
•c6erk/;iK(jonr C^rifiJrcn Smcc 1977
•LACEMENT
Foster Home Shelter Residential jGroup Home Relative Other
/ Date Placed
V I S I T A T I O N R E P O R T S U M M A R Y
PATE OfVISIT W ' - ' I S ' ^ ^ ^ NEXT COURT PATE NAME of CHILPNAME/APPRESS ofPLACEMENT CCKJ^IAA e/v^
, ZIP CODE Relationship
VISIT:
po>^>"^^^^uAj;^ UNANNOUNCED ANNOUNCED _
NAME of COUNSELOR L ^ Q - f e p f - ]lf;>ndi/U^EL NATIONS/INFORMATION i
UNIT Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS 1. CONDITIONofHOME Acceptable T * ^ Environment Safe for Child 'Y ' " ' ^ - ^ Sufficient Food 7 -£- \ Toys/Play area ' Y ' ^ Total number ofchildren in home Ages Siblings DEStCRIBE C_VAvVgi) t« . jO^ '^ <=^<C«g-Vt V ^ -Voot U/^.>c^.^JP_ f ^ V
in the CASE NARRATIVE.
•4^*-^ \ / i .<s . .>^^ V % I c X M?ga.M. ^ ' X ^ . ^ . z ^
V 2. CONDITIONofCHILD Healthy "Y^-S WellNourished. Placement Appropriate Signs ofNeglect/ Abuse ^<[^
Behavior M o r - A ^
OBSERVATIONS ofCHILD .4L
C J U ^ /
^
r^ l - ^(g-^ '^nr-J - i ^ ^ ^ Q ^ IT- «-^T=y ^
FAHIS/LICENSING notified /
<K. \ . ^ a: .-d^ Sl^/>»-R, ^ . ^ ^ ^J2^
3. SERVreSES NEEPEP Name: School Grade Pay Care Neighborhood Center Health Care: Medical Immunizations Dental Hearing Vision Mental Health CMS SSI_ Counseling/Therapy Clothing. Tutoring
Substance Abuse Newbom Developmental: Early Intervention (0-5) _ Independent Living: Assessment Curriculum Plan Economic Services Relative Caregiver Housing _
Parenting Classes FDLRS
Therapeutic Visitation FSPT CRC
Pregnancy Services 16+ Vocational
^^^ssessments: Comprehensive f | | ^ o l I o w up Actions C X V A 4 < ^
Mental Health ^Behavioral Domestic Violence
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Academic
^ r
DJJ Exit Interviews _
Developmental
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available. CONTAINS Medicaid/Medipass Card.
Detention Order Case Plans _ MEDICAL Physician
Dental FSPT
Current Reviewed
^tel_ Last Visit
_ Copies of Social Security Card Judicial Review Social Study Reports
Annual Physical / / / / Hearing Vision
. & Birth Certificate Day Care
Last seen by Doctor / / Developmental
5. COUNSELOR OBSERVATIONS d J u -" -^—^ y - - -
6. FOOTER PARENT/S^IESTER/F
Case Manager
JL. <sa-f-p
fER PARENT/SHmiTER/RELATIVE/SCHOOL/PROVIDER CQMMENTS
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7. CHILP'S COMMENTS C-Ax>^Jt o l < r»'=>->rL.i2^ "-^yS-^^jz^^ U - g ^ V ^ c R g , y c ^ J ^ i v^_g^
8. PROGRESS TOWARPS GOAL
9. FOLLOW UP/RECOMMENPATIONS for NEXT VISIT
, J f k 0 . FAMILY VISITATION Parents. P^briSERVATIONS
. Siblings
Signature date / Signature date :AREGIVER/OTHER COUNSELOR - PI/PS/FC
/Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOWCOPY-SUPERVISOR
ignaturevJ ^ date SUPERVISORY REVIEW
PINK COPY - CAREGIVER/PROVIDER
C ' 7 * Center for liamily S
Child Enrichment, lnc ^ x i v J m i Olir djifitmi 'mtx t077
^..ACEMENT Foster Home
_ Shelter Residential
jGroup Home Relative Other
VISITATION REPORT SUMMARY
Date Placed PATE OfVISIT / 0 - / 4 - O C NEXT COURT PATE NAME of CHILP NAME/APPRESS of PLACEMENTCg^«-u.A.a-^
POB
Complete blanks with yes or no and 1. CONPITION OfHOME Acceptable ^ (L5 Environment Total number ofchildren in home
Relationship - ^ n ^ - ^ - C j ^ e^Qj-.X^cu-'^sr-VISIT: ANNOUNCED 1 ^ UNANNOUNCED
NAME of COUNSELOR / ^ g J ^ g V ^ llp-/iU^/j>4^TEL4» describe status. EXPLAIN OBSERVATIONS/INFORMATION in the
ZIP CODE
._:!:rr ^ UNIT 7 7 ^ ASE NARRATIVE.
Safe for Child "Y^e..? Sufficient Food V e ^ S Toys/Play area Ages Siblings
DESCRIBE
' C t - f y t ^ P>Ct-
C_r>yT^gA.t:Vl .A.
U i i «=L.S ' 5 g-g^vA. \ NA -V-e o ^ UQW"^ o ^ U=k&L ^Axy V C ^ i ^ ^ - l • . ^ - > a ^ W . g
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V^pPi/^.'-g^-SL ^ < L X ^ C I L K S ( Placement Appropriate
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vrer 3. SERVICESNEEDED Name: S c h o o l _ Health Care: Medical Immunizations Counseling/Therapy
Grade Day Care_ Dental
Clothing. Hearing Vision
Neighborhood Center Mental Health CMS SSI
Tutoring. Parenting Classes FDLRS Developmental: Early Intervention (0-5) Substance Abuse Newbom
Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ _ Economic Services Relative Caregiver Housing Vocational Domestic Violence
sessments: Comprehensive Mental Health ^ llow up Actions \ ' U e . , X r ^ c J ^ . ^ - U>{£^-\<^\^y~ >A>g»-^
Therapeutic Visitation FSPT CRC
DJJ Exit Interviews
WJ rH^-;
Behavioral Substance Abuse _ ^ _ _ Academ ic Developmental^
UCA-/^.. Q C e _ gCH^ XECOR
r>i Ui (j-->i^<-i>^.^S'-^ 4. CLIENT RESOURCE R E C O R P (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical __ /__ /
Dental Last Visit __/___/ Hearing Vision FSPT
5. COUNSELOR OBSERVATIONS
Current Reviewed & Birth Certificate
Day Care Last seen by Doctor __/__/_
Developmental
^ ^ ^ ^ E \A3q.-Vg-U
f FOSTER PARENT/SHEL' TER/RELATIVE/i
= ^ ^
/SCHOOL/PROVIDER COMMENTS'^Uw;
a ISSUES re: SERVICES
7. CHILD'S COMMENTS _CI
7
l^-^SL.
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENPATIONS for NEXT VISIT
FAMILY VISITATION Parents 'BSEI\V^^NS
. Siblings. Therapeutic Dates
z ^ - ^ ' Mac ,^:fi^>^^ fcjl/fj-'. Signature date
CAREGIVER/OTHER Acknowledgement only that Counselor visited
WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
Signature date COUNSELOR - PI/PS/FC
^g r i a tu r e U {, date SUPERVISORY REVIEW
Center for Family § Child Enrichment, Inc
• ( c T
VISITATION REPORT SUMMARY /«ryiiK.iotirCf;if^rtimo: 1977
JACEMENT . Foster Home . Shelter . Residential Group Home Relative Other
/ / Date Placed
DATE ofVISIT l O - l G - t O ^ NEXT COURT DATE NAME of CHILDM U b f ot ^^0~CLt-j-c^ P^-.^ DOB N AME/APPRESS OfPLACEMENT
« ZIPCODE
/ /
R e i a t i o n s i i i p J l ^ S ^ ^ ^ ^ ^ Z I ^ ^ ^ ^ ^ ^ ^ ^ VISIT: ANNOlJNCED ^ ^ UNANNOUNCED
NAME OfCOUNSELOR EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE. Complete blanks with yes or no and describe status.
1. CONDITIONofHOME Acceptable Y * ^ Environment Safe for Child 7 " ^ Sufficient Food " Y - ^ ^ Toys/Play area Total number ofchildren in home Ages Siblings „ PRESCRIBE O t / L - l o l VAi) c^JL ? ^ g C L A ^ \ ^ ^ - t ^ - o g , L t v ^ »a>»-.g
i . f e n i a , J E L 4 ^ ^ ^ - £ / . T ^ J u N I T '
)ESCRIBI
\\<^<^^3h&'^^^-G ' - i - ' ' ' — ' ^ ) ^ I S - t j :^r(^vQ_ J /JL S^
3 ^^-c^^^-rS- C C C ^ - * N » ^ W t f t ; ! ^ ^ - ^ ^ ^ T ^ ^ g ' v ^
2. CONPITION of CHILP Healthv V c 3 WellNourished Placement Appropriate OBSERVATIONS of CHILP — | g ^ - a -
Behavior K J o r-\A<A^gOL Q3-eJU-.'=<.Ag f Signs ofNeglect/ Abuse {JJQ \ t / u J L t C <=j<j^ ~Z^r-^ FAHIS/LICENSING notified
\ ^ \ J S
t^A^-e-,' 3. SERVICES NEE&EP Name: School _ Health Care: Medical Immunizations Counseling/Therapy
Grade Pay Care_ Dental
Clothing. Hearing Vision
Tutoring Substance Abuse Newbom Pevelopmental: Early Intervention (0-5)
Independent Living: Assessment Curriculum Plan. Economic Services Relative Caregiver Housing _
Parenting Classes FDLRS
Neighborhood Center . Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
Pregnancy Services 16+ DJJ Vocational Domestic Violence
^^sessments: Comprehensive ^Billow up Actions 'Yyg-
Mental Health Behavioral <g^'=<-i-Va.. -VO-^aA- - k > q A - i \
Substance Abuse
l . T ^ ^ <"^ ^ i ^
Academic _Exit Interviews _ _ Developmental_
^ r 4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical ___/__/
Dental Last Visit / / Hearing Vision FSPT ^Case Manager
Current Reviewed . & Birth Certificate
Day Care Last seen by Doctor / /
Developmental tel
5. XOUNSELOR OBSERVATIONS 1 oog— SV\^
A A L A J ^ C O L V/VA
V — ^ H ^ ^ <^-A^ \ *A ( C « . ( • F l .U t O
c y C A - J L / ^ fr
^ VA^ri-M
6. FOSTER PARENT/SHELTER/RELATIVE/SCH
V- ^>A-c.>V-
IDER COMMENTS.
ISSUES re: SERVICES ^ ^ ^ -~V-=:^dl<]^
•-V-A,:av^4- " ^Z . *^^ ' ^ Q ^ '~-i - g J -t. sa-C7 9-tL^~Si ^ ^
V > - « - ^ 3 f^i PROGRESS TOWARDS GOAL
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
FAMILY VISITATION Parents OBSERVATIONS
. Siblings Therapeutic_ Dates
Signature date CAREGIVER/OTHER
/Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
^ ^ n
Center for Family § . Child Enrichment, lnc
•
^XTiJmi our c(rif()reM itirtcc 1977
LACEMENT
Foster Home Shelter Residential Group Home Relative Other
C--! CSQ
/ / Date Placed
VISITATION REPORT SUMMARY
DATE OfVISIT < / / 4 f / p ^ NEXTJCOURT PATE NAME of CHILP NAME/APPR
Relationship—>g"^^ g=>-VISIT: ANNOUNCED
NAME OfCOUNSELOR
^ & of PLACEMENT ^2>L
• ^ ' ^ •^^gL->_>v^
tJNAN>
ZIP CODE
JNANNOUNCED TEL UNIT
EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE. Complete blanks with yes or no and describe status. 1. CONDITIONofHOME /s Acceptable Y ^ g ^ Environment Safe for C h i l d ^ > £ ^ Sufficient Food V^<igLJg Toys/Play area ^ - c S ^ Total number ofchildren in home Ages Siblings. DESCRIBE C J J j ^ Vg5< vi<W-i2L '^^> g- « a - ^ \ \ ^ -4r^.^.Q \y\
V
2. CONDITIONofCHILD Healthy WellNourished Placement Appropriate OBSERVATIONS ofCHILD
N£>i vJV-jaSai
^ ^ . . . x • • ^ . .
rd t :%=S__kL^Lt=4,^S^ < g a ^ :3: ^-^og j
Signs of >Jegl^t/ Abuse N A 5:?r V U.^=JUv c:%^ Behavior \ d ry^
3. SERVICES NEEDED Nhme: School Health Care: Medical Immunizations Counseling/Therapy
Dental Clothing
Hearing Vision Tutoring
Substance Abuse Newbom Developmental: Early Intervention (0-5) Independent Living: Assessment Curriculum Plan Economic Services Relative Caregiver , Housing _
Parenting Classes FDLRS
Neighborhood Center Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
Pregnancy Services 16+ Vocational Domestic Violence
Assessments: Comprehensive_ Follow up Actions
Mental Health Behavioral Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical / /
Dental Last Visit / / Hearing Vision FSPT .^ Case Manager
5. COUNSELOROBSERVATIONS
_ Current . & Birth Certificate
Day Care
Reviewed
Last seen by Doctor / / . Developmental
)ROBSl U t C ^ c X \i <=>~fl=> g^ ,^ y M >••.-<?>
^ - & i ^ 53> «~t A
tel ^ ^
1 , ! > - ^ ^ -Gug. \ ^ % . I K V Z _CL 6^0STERPARENT/SHELTER/RELATIVl/SCH00L/PR0VIDER"t:0MMENp"i;^ I-
: SERVICES »
' ^ . y ^ .
\ " r^—SLr
ISSUES re: SERVICES
7. CHILD'S COMMENTS C J U - > 3 - g ^ ^ g a . - 4 L _ 4 < a , ^-V^^A.-g'V.S?^ ^^^^i5- \ ^ < ^ > 0 ^ V " u ^ \
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENPATIONS for NEXT VISIT
m . FAMILY VISITATION Parents. •MHRVATIONS
. Siblings. . Therapeutic Dates
I Signature date Signature date CAREGIVER/OTHER
Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
COUNSELOR - PI/PS/FC Signature / date
SUPERVISORY REVIEW
Center for liamily § Child Enrichment, lnc
idniui OUT dMarcn Smce 1977
ACEMENT . Foster Home . Shelter . Residential Group Home . Relative Other
5'' / /
4' < 3 ^ ^
VISITATION REPORT SUMMARY
Date Placed DATE OfVISIT * ? - p / ^ - - 0 NAME ofCHILDNdfe^ /y r p Q g d ^
NEXT COURT DATE
NAME/APPRESS ofPLACEMENT C
Relationship \-C>f:;,f\-^Jtr- -f=»c>.-r~ eA->>>>Sr VISIT: ANlfJOLrtiCED,^_» UNANNOUNCED
lb»a^i<^jj:L
ZIP CODE
NAME OfCOUNSELOR UNIT Complete blanks with yes or no and describe status. 1. CONDITIONofHOME Acceptable Y ^ ^ ^ Environment Safe for Child Total number ofchildren in home Ages _ PESCRIBE C ^ U ^ t t «A
EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE.
V ' ^
=='*--«-'C-caJ i - ^ - ^
Sufficient F o o d ' ^ g - g . Toys/Play area ^ ^ ^ ^ Siblings
-•V-gy Vgj €> ^ - " ^ v ^ T * ^ " ' ^ C J ^
2. CONPITION OfCHILD H e a l t h y ^ < & A WellNourished Placement Appropriate Signs ofNeglect/ Abuse
Behavior KJOrnA ' ^ ^ i t i \ i^rtV.< c-^t.^-^g-if— FAHIS/LICENSING notified I'lacement Appropriate tJigns of Neglect/ Abuse A X Q -^. . .. . ._
OBSERVATIONS of CHILD C L - U - ^ L c d ^3>^^S('-•e^^pLjr^ - ^ ^ ^ LAg> ^ <:^^^ <o\ Wg:i \ vT JLJ g-Sir < a . ^ <aJig? ,.>j;ic< -£3J i d . ^
3. SERVICES NEEDED Name: School _ Health Care: Medical Immunizations Counseling/Therapy
Grade Day Care_ Dental Hearing Vision
Clothing. Tutoring. Developmental: Early Intervention (0-5) Independent Living: Assessment Curriculum Economic Services
Substance Abuse Newbom Parenting Classes
FDLRS
Neighborhood Center , Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
Plan Pregnancy Services 16+ DJJ Relative Caregiver Housing Vocational Domestic Violence
Assessments: Comprehensive_ Follow up Actions
Mental Health Behavioral Substance Abuse Academic Exit Interviews _
_ Developmental_
Current & Birth Certificate.
Day Care . Last seen by Doctor __/__/_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical / /
Dental Last Visit / / Hearing Vision FSPT Case Manager
5. COUNSELOR OBSERVATIONS C : L J A ^ S J^ i ,L .»^*-a> ^ J U - ^ o
<:>^^^^^ . 'fp'-^-e L S P^V'=tt^ t >^^^—. \y^^CS-^ i
Reviewed
Developmental
6. FOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDER
4^.^:^
jiER COMMENTS \ l ^ J ^ ^ ' J c - ^ ^ j T g^xaut-^.e.^ ^^<V-
^ ^ —i-A- ISSUES re: SERVICES
"A ^ « ' - \€-..-wa.v:^ '^=/<^^-C~ .:JtE3\ '^
HILD'S COMMENTS C!lJi Wv...V = »
\ < ^ ^
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
ii Si. FAMILY VISITATION Parents BSjERVATIONS
. Siblings Therapeutic_ Dates
{ Signature Signature date' COUNSELOR - PI/PS/FC
Signatured^ / date SUPERVISORY REVIEWif CAREGIVER/OTHER
' Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
^ » ^
Center for Family &
•
Child Enrichment, lnc |-c6erij(iinii oil rcfri/ttrcH iince 1977
fPLACEMENT
Foster Home Shelter Residential ^Group Home Relative Other
8 i I f u - ^ f VISITATION REPORT SUMMARY
/ Date Placed
DATE of VISIT J NAMEofCHILD
0 ( ^ NEXT COURT DATE g7>/V t y p e - D O B / ^ 1 ' 2 ^ <DO
NAME/APPRESS ofPLACEMENT
Relationship J f - c s ^ j ^-e-jr- C>e AMMni rMTPn M T
ZIP CODE
V l S n : AlNNUUlNt.;bU- -UINAlNNUUlNCbUV.^'^ ^COUNSELOR (^^i<L«> V T W ^ ( " ) C E L ^ ? ^ / , ^ r > C ^ U N I T 7 7 6 : ^ EXPLAIN OBSERVATIONS/INFORMATION in theCASENARRATIVE. /
VISIT: ANNOUN.CEDr^ _^UNANNOUNCEDl ^ NAME of <
Complete blanks with yes or no and describe status. EXPLAIN < 1. CONDITIONofHOME Acceptable y ' ^ Environment Safe for Child T ' ^ A Sufficient F o o d ^ « = ^ Toys/Play area. Total number of children in home Ages ^ Siblings DESCRIBE C W ^ \ o V v ^ ^ o . ^ ^
M^^«g ^^—' ryx. ^ & X
' siyj V.A>ia
~V<^^ L ^ d g = < -
. >oi?. i uu^
-A>g\ VA ' -X? i 2. CONPITION of CHILP Healthy WellNourished Placement Appropriate OBSERVATIONS of CHILP.
Signs ofNeglect/ Abuse ^^jbo \ v/ e3\_X Behavior
^
e_LccOJ (<=r7^
^ ^ TA ' ^
c . r a g r s r y - FAHIS/LICENSIN notified i
Gnot 1 1
3. SERVICES NEEPEP Name: School _ Health Care: Medical Immunizations Counseling/Therapy
a ^
Grade Pay Care_ Dental Hearing Vision
Clothing. Tutoring Parenting Classes FDLRS
m Developmental: Early Intervention (0-5) Substance Abuse Newbom Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ _ Economic Services Relative Caregiver Housing Vocational Domestic Violence
Neighborhood Center . Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
^Assessments: Comprehensive Mental Health Behavioral IFFoHow up Actions CS^A-<.J^ < S \ \ "r^ "gs
Substance Abuse Academic
DJJ Exit Interviews
Developmental_
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available. CONTAINS Medicaid/Medipass Card.
Detention Order Case Plans _ MEDICAL Physician
Dental FSPT
Current Reviewed
tel_ Last Visit
_ Copies ofSocial Security Card Judicial Review Social Study Reports
Annual Physical / / / / Hearing Vision
. & Birth Certificate Day Care
Last seen by Doctor __/__/_ Developmental
5. COUNSELOR OBSERVATI .Case Manager tel « rt
-f \ > ^ ^ . - ^ i s
- ^ ^ - ^ 6. FOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDER COMMENTS
oSL-s-.^' tlf*^ ^ <0"<-.^ .
ISSUES re: SERVICES
7. CHILD'S COM X
IMENTS < : l A w w S 3 ( o ^ 'g^,g>-^-^=a^ ^ - ^
cS^^-<:3^ a 8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
# 10. FAMILY VISITATION Parents OBSERVATIONS
. Siblings Therapeutic_ Dates
Signature date CAREGIVER/OTHER
Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
Signature date COUNSELOR - PI/PS/FC
^ ^ ^ S^-S s?
fr Center for Family &
Child Enrichment, Inc VISITATION REPORT SUMMARY d«rijf;iK(joitrC6iftlrctiM"HCC 1977
PLACEMENT _ Foster Home _ Shelter _ Residential _Group Home _ Relative
Other
/ / Date Placed
DATEofVISIT NAMEofCHILD
( > j l C J c > < h NEXT COURT
3S ofPLACEMENT ^ J 3 > - J ^ V > . A - < 2 -
OURT DATE
DOB^^^^S; NAME/ADDRESS ofPLACEMENT
ANNOUHCED ^ w.-r^..,i^^w.-v.i^y y .^ ^ NAME of COUNSELOR / ritJ^e^e-V \Ur>£tCjl O'EL lp fZ- fZZd?^VNlT ( 7 ^
Complete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION intheCASENARRATIVE. ' 1. CONDITIONofHOME Acceptable Y ' ^ Environment Safe for Child _ [ Y _ ^ ^ ^ Sufficient F o o d ' ^ <aA Toys/Play area Total number ofchildren in honie Ages DESCRIBE C _ M . ^ <A^ j A ^ ^ w a . . < ^ g ^
Siblings.
^ S • « \
X^A-A -yC/^-SL V y l ^ l A ^ A . ^ < ^ ' T 7 j j&saA.^
v>^^-g 0 ^ ^ ^ ^ i i - ^ — ^ i , ' a \ \y>^-<^ c- (jvT. 2. CONDI Healthy
ION of CHILD Well Nourished
Placement Appropriate OBSERVATIQNS ofCHILD
Behavior ( J l O ^ ' ' n A A . j P ^ ^ lg? g J U - O U Q ( crY~' Signs of Neglecf Abuse ^ g \ v / y ^ J U c c ^ M - y - y - " FAHIS/LICENSING notified / /
^ \ o
^
^ ^
3. SERVICES NEEDED Name: School _ Health Care: Medical Immunizations Counseling/Therapy
Grade Day Care_ Dental
Clothing. _ Hearing Vision
Tutoring. Parenting Classes FDLRS Developmental: Early Intervention (0-5) Substance Abuse Newbom
Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ _ Economic Services Relative Caregiver Housing Vocational Domestic Violence
Neighborhood Center . Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
DJJ Exit Interviews
#ssessments: Comprehensive Mental Health Behavioral _j SubstanceAbuse ;_^Academic Developmental
ollow up Actions < _ \ A ^ . «4^ ' ' ^ caa.4|-«a<.v^ t ^ \ i ^ ^ ^ \ t \ .0 \ ^ a ^ V ^ ^ \ ^ ^ t ^ n x. / y v v f t .•<B\^ \y<~s? g=Lg^ J 4 = S f<-JL<>^>--g^
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4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical / /
Dental Last Visit / / Hearing FSPT_
S^OUNSELOR
Current Reviewed . & Birth Certificate
Day Care Last seen by Doctor / /
Vision Developmental
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Case Manager OBSERVATIONS C J U ^ \ a X ^ M A to e
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6. FOSTER-E>ARl i/SHEL E/SCHOOL/PROVIDER COMMENTS
ISSUES re: SERVICES
7. JCHILD'S COMMENTS 'iS g— - < ^
8. PROGRESSTOWARDSGOAL
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT
p. FAMILY VISITATION Parents )BSE|RVA1
Siblings. Therapeutic Dates
> Sienature date — " ^ S i Signature date COUNSELOR - PI/PS/FC
itttre da!e-CAREGIVER/OTHER
Cknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
Signatuip date SUPERVISORY REVIEW
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lenter for Family § i Enridiment, Inc ^r«/;rn^ owr d p b n n SIHCC 1977
PLACEMENT Foster Home Shelter
VISITATION REPORT SUMMARY
/ _ / _ Date Placed
DATE OfVISIT / ^ / / f i ^ T - NEXT COURT'. NAME Of Child A h i J r ^ ^ t ^ ^ 7 ^ ^ > ^ X a / \ DOB < / 2 ^ / Q O
DATE
Residential Facility Group Home Relationship
VISIT: ANNQUNCED ) /
ZIP CODE
Complete blanks with yes or no and describe stati 1. CONDITION OF HOME Acceptable Environment Safe for Child
UNIT NARRATIVE
Sufficient Food Toys/Play area '= ys, i' LX> 4oxy(-0j^za^
Has the number of occupants in the home changed? Yes No If so, please list the name, date of birth and social security number of the new occupant(s). If the new occupant is another foster child, please omit. Name DOB SS#
2. CONDITION of CHILD
Sealthv O A Q y ^ WellNourished
ac
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acement Apfpropriate M-^S/^ Signs of Neg: of CHII JSERVATIONS
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J. SERVICES NEEDED Name: School f Care Neighborhood Center 'Health Care: Medical Immunizations Dental Hearing \ VPsion Menta Counseling/Therapy "> / Clothing ^ j TuK)ring Parenting Classes Therapeutic Visitation Developmental: Early Intervy^iifion)(9/5)_^\_ Substance Abyi e NeWb/m,^. FDLRS FSPT 'N / C R C Early IntervemionyO Independent Living: Assessmei
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SSI
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ICE
BehavioraL Vocational
Substance Al Domestic Viol'
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Detention Order Case Plans MEDICAL Physician
Current Reviewed Copies ofSocial Security Card_ Birth Certificate
Judicial Review Social Study Reports tel
Last Seen by Doctor_ Hearing / / FSPT
/ / Dental_ Vision /
Day Care Annual Physical_
Last Visit / / /
/ Developmental_
LOR OBSERVATIONS y^^-^-^U^) Case Manager tel
^Ps^rf^ NT/SHELTER/RELATIVE/SCHOOL
ISSUES
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FAMILY VISITATION Parents JSERVATIONS
Therapeutic_ Dates
Signature Signature date
COUNSELOR - PI/PS/FC
Signature / date
SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only tbat Coun'selor visited
WHITE COPY - CASE FILE • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER
(enter for fiamily S ( i d Enrichment, Inc
^ E . | p £ M E N T ^5=_T^oster Home * Shelter
Residential Group Home Relative Other
^
/ / Date Placed
V I S I T A T I O N R E P O R T S
DATE OfVISIT ' V ' l . f S ' ^ D U NEXT COURT DATE W^^ Q ^ Q D NAME of C H I L D r M _ \ V ^ ; C . r X V S r O r D O B ^ g t ^ - i D O NAME/ADDRESS of PLACEMENT PrX^rv^rNt^* , C"^ ^
.; ZIP CODE ^r^] Relationship ViA-^r<.M-^^ . X ^ < g r t > 3 U / K © « 2 ^ ) ^ ? > ? ? \ fo3
VISIT: ANNOUNCED _ UJiANNOUNCEa. V*^ -NAME ofCOUNSELOR/>^y\;l g p ^ " C . T E L ^ t ^ - U g ^ - ? UNIT " ^ " T M
Compiete blanks with yes or no and describe status. EXPLAIN OBSERVATIONS/INFORMATION in the CASE NARRATIVE. \. CONDITIONofHOME Acceptable \ f - P ^ Environment Safe for Child \ y - C - ^
ildren in home *^ ^ "»« ^ ' — -J—^
Ueo Total number DESCRIBE
C Ages g^- -E^ Sufficient Food
Siblings ^
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_ _ i _ _ _ FAHlS/LICENS.INGrnotified / /
3. SERVICESNEEDED Name: School l rade V DayCaTe Health Care: Medical_ Counseling/Therapy
Immunizations Dental Clothing
Hearing Vision Tutoring Parenting Classes
FDLRS Developmental: Early Intervention (0-5) Substance Abuse Newborn _ Independent Living: Assessment Curriculum Plan Pregnancy Services Economic Services
Neighborhood Center . Mental Health CMS
Therapeutic Visitation FSPT CRC
SSI
16+ Relative Caregiver
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v jsessments: Comprehensive_
llow up Actions Mental Health
Housing Behavioral
Vocational Domestic Violence Substance Abuse Academic
DJJ Exit Interviews _
Developmental_
/ /
4. CLIENT RESOURCE RECORD (Blue Book-Stays with Child) Available CONTAINS Medicaid/Medipass Card Copies of Social Security Card
Detention Order Case Plans Judicial Review Social Study Reports MEDICAL Physician tel Annual Physical
Dental FSPT
5. COUNSELOR
Current Reviewed & Birth Certificate.
Day Care tel
Last Visit / / Last seen by Doctor / /
Hearing Vision Developmental FSPT Case Manager _tel
SBLOROBSERVATIONS ^-(Kl> r W c V l , O i p / ? J p Q i / ^ C i U c ^ . / ' p c ^
6. FOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDER COMMENTS f>. ( (^C/^ ^
ISSUES re: SERVICES f \ ^ Q y t / ^ - < -
7. CHILD'S COMMENTS KV(0
8. PROGRESS TOWARDS G O A L ' - ^ h J g ^ ' g C K o j l -gs. "Lx^-A."tr i o o<Wg /g )^T^
9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT \ r \ (T) A^vA ^ A ^ - "--U-^^^V,^ "^^^^L |fl. FAMILY VISITATION Parents ' j—(. O Siblings V — t Q Therapeutic Dates RESERVATIONS
Signature date CAREGIVER/OTHER
Acknowledgement only that Counselor visited WHITE COPY-CASE FILE • YELLOW COPY-SUPERVISOR • PINK COPY-CAREGIVER/PROVIDER
Signature date COUNSELOR - PI/PS/FC
Signature date SUPERVISORY REVIEW