County of los angeles department of children and family services
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This is a(n): Initial Placement Update to the initial DCFS 709 (Within 30 Days)
Replacement Modification of Needs or Plan
SOCIAL SECURITY #
DATE OF BIRTH
CHILD’S PRIMARY LANGUAGE
CURRENT FOSTER CAREGIVER NAME
DATE PLACED IN CURRENT CAREGIVER’S HOME
CAREGIVER ADDRESS (Street, City, State, Zip)
SPECIFIC FOR THIS PLACEMENT
Attach Child’s CWS/CMS Case Plan Individual Client Responsibilities ( For Update, Replacement or Annual Reevaluation)
See FYI 03-19 for guidance in completing this section.
Regional Center Involvement
No None Known
Yes Regional Center:
Gay Lesbian Bisexual Transgender Questioning Heterosexual Comments:
EDUCATION (Include name, address, dates of schools attended, grade level, etc.)
IEP Provided Special Education DCFS 1399 Provided
Education Rights held by: Parent Other If other, whom?
PLACEMENT/DETENTION HISTORY (Reason for Placement and/or detention history)
No Prior Placements Foster Family Home(s) FFA Group Home(s) Relative Other
VISITATION PLAN (Include visitation frequency, schedule, with whom, monitored, include sibling(s) name(s). If the sibling’s caregiver gives permission, include the caregiver’s name and phone number). Plan:
HEALTH AND EDUCATION PASSPORT (HEP)
FOR INITIAL PLACEMENT: HEP information given to Caregiver on:
FOR UPDATES TO THE INITIAL DCFS 709 (Within 30 Days): HEP given to Caregiver on:
FOR REPLACEMENT: HEP information including additional medical and education information from prior
placement, given to Caregiver on:
The attached Health and Education Passport contains the following information. Annotate the HEP as needed. Explain any missing information.
Check if Information available on HEP A. HEALTH CARE PROVIDERS Name Address Phone Date last seen If not available, explain
B. ALLERGIES (List all known food, drug and other allergies and reaction)
None Known Yes No, explain
Yes No, explain
D. MEDICAL/PSYCHOLOGICAL (Significant past/present or chronic conditions)
None Known Yes No, explain
Indicate if the following information is currently available in the Health and Education Passport. Provide an explanation for any missing information.
Medication(s) Prescribed/Medical Equipment/Tx Plan
Date Medications Discontinued
(If no, explain)
Caregiver reviewed, understands and agrees to support the child’s case plan as described above; has determined the child is compatible with others in the home. Caregiver agrees to keep all of the child’s case information confidential and understands that unauthorized disclosure could result in a fine up to $1,000. Caregiver acknowledges receipt of the Health and Education Passport with the above information included or an explanation of why the information is not included.
Caregiver’s Signature Date
Print CSW’s Name
DCFS 709 (Rev 12/03) Page of