County of los angeles department of children and family services




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COUNTY OF LOS ANGELES DEPARTMENT OF CHILDREN AND FAMILY SERVICES
FOSTER CHILD’S NEEDS AND CASE PLAN SUMMARY

Check One: This is a(n):  Initial Placement  Update to the initial DCFS 709 (Within 30 Days)

 Replacement  Modification of Needs or Plan

 Annual Reevaluation



CHILD/CASE IDENTIFICATION





CHILD’S NAME

SOCIAL SECURITY #

SEX

AGE

DATE OF BIRTH

CHILD’S PRIMARY LANGUAGE

     

    -    -     

 

     

     

     

CASE NAME

STATE NUMBER

CSIS Number

RELIGIOUS PREFERENCE

     

     

     

     

CURRENT FOSTER CAREGIVER NAME

PHONE NO.

DATE PLACED IN CURRENT CAREGIVER’S HOME

     

     

     

CAREGIVER ADDRESS (Street, City, State, Zip)

     




INFORMATION 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:

     

Service Coordinator:

     

Phone

     



EMOTIONAL/PSYCHOLOGICAL


Comments:      

BEHAVIOR/SOCIAL


Comments:      

SEXUAL ORIENTATION/GENDER IDENTITY Youth self-identifies as

 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?

     

Comments:      







PLACEMENT/DETENTION HISTORY (Reason for Placement and/or detention history)







 No Prior Placements  Foster Family Home(s)  FFA  Group Home(s)  Relative  Other

     

Comments:      




ABILITY OF CHILD TO HANDLE HIS/HER OWN ALLOWANCE AND OTHER CASH RESOURCES


Comments:      

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:      


OTHER COMMENTS (Include child’s likes, dislikes, other special needs, formula, etc.)

     

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


Child’s Physician:

   

     

Child’s Dentist:

   

     

Other:

     

   

     

     

B. ALLERGIES (List all known food, drug and other allergies and reaction)





 None Known  Yes  No, explain

Comments:      

C. IMMUNIZATIONS





 Yes  No, explain

Comments:      

D. MEDICAL/PSYCHOLOGICAL PROBLEMS (Significant past/present or chronic conditions)




 None Known  Yes  No, explain

Comments:      


Indicate if the following information is currently available in the Health and Education Passport. Provide an explanation for any missing information.

Date Diagnosed

Primary Diagnosis(es)

Contagious/ Infectious

Medication(s) Prescribed/Medical Equipment/Tx Plan

Date Medications Discontinued

 Yes  No

 Yes  No

 Yes  No

 Yes  No

 Yes  No

(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

Office Address

Phone












     

CSW’S Signature

Date




DCFS 709 (Rev 12/03) Page of


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