c/ier«/jrrujOMr Oplincn Since HJ77 - dcf.state.fl.us · EXPLAIN OBSERVATIONS/INFORMATION in the...

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 .^yî^m?

ZIP COPE ^ T A ^ S Relationship XP^,f^'pÂ.^(p ,^yu2î^

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- (?yn4yiî^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^Ô^ - ^ 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 \^âtion 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 /yyûbstance^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^//^^

:iÎN/j notffted E/LICENSING notifled // / ^yn/)

Neighborhood Center Health Care: Medical Counseling/Therapy Developmental Independent Living . , Economic Services J^y^Welatiy^Ca'regiver A^yôusing Â<* 'VopationalA / Assessments: Comprehfensive /v-fAJMental Healtllxy/êhavioral 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

ÂlAyC&fnn r?

p A l ^ J 2 y i ^ A 0 X , y \ ! p - . fP(APâ^Xyj0ÂAPyJ>7aXZ^ -ÂJAAX,.^Jay7.-Cf^ 1AP.Q^ OyiyiQQ(AUl 6. FOSTER PARENT/SHELTER/RELAmE/ZCbOOL/PROVIDERCQAlMENTS (f-^^^jgyLiZx^ôCAÂ . ^ ^

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

^ * ' ^ / " ^ - ^


_ / / _ 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

«



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


/ _ / 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 theûmber 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

ÔBSERV

^ , & A t L A ^ O^-^lr-i-J^

$ ^

S ' ^ ^ f i ^ HOTLINMÊNSMG 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; fûbstancarAbuse 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


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:ô

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/-JÔy\ - 0 ^ t 9. FOLLOW UP/RECOMMENDATIONS for NEXT VISIT

10. FAMILY VISITATION Parents OBSERVATIONS

_ Sibling Therapeutic_ Dates

Signature date Signature date


Signature c date


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


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^-ÔO 'yj^

A Has the numbff of occupants in the home changed? Yes No

/ C J V o j g ^


2. CONDITIO; Healthy,

OfCHILD Well Nourished"

Placement Appropriate BSERVATIONS o£ \'^~<^ \0YiCUl €

lA -*^ Behavii j YSigas ofNegl^tûse,

^ : ^

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^âreptigg Classes Tiierapeutic

[oSr^^SubstaneeAbus ^ " ' • ^ ' - "^^" ' /^/<ûn-icuj^m N / f f Pl;

Ibuse NewlômW^^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


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 / ^ ^ ^


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


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 ^ûUbCQu

MENTS

NEXT COURT DATE

, Residential Facility , Group Home Relative Other

NAME/ADDRESS OF PLACEMENT T CAArrne / c ^ -DOB s r ^ l iSôoo

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 ^ Â^^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?


2. CONDITION OfCHILD Healthv ^KffY\ Well Nourished_ Placement'Appropriate KA{9^ Signs of Ne lqctf Abuse_

OBSERVATIONS of < U 9 - ^ Signs of Negi CHILD AÔ/fol

QCt7i £_ Behavior

/ O D ' >- <a-> /;2^<;gy^^.Aî-<3

'={^49<:,jC.£^:Jjl_. .-j:^. g o c J . H0TLIN6/LICENSIN'

jh^îM^ &\Yjl<fÂj^~P 3NSINC^notified V / ' ' ~

o/AeA^ (KhxJsî^)-^ 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 /^/yjtî 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,


Detention Order Case Plans Judicial Review Social Study Reports


MEDICAL Physician, tel Last Seen by Doctor_ Hearing / / FSPT

/ / Dental, Vision /

Day Care Aimual Physical

Last Visit / / /

Developmental, Case Manager .

5. COUNSELOR OBSERVATIONS <î^—/U''^ A A^dZtd^Yi 0 Y : ^ y \ £ L ^ 'Ld^zS2y ^^-^yyJe.^

6. FjOSTER PARENT/SHELTERJRELATIVE/SCHOOL/PROVIDER COMMENTS p^ôix>^/^ J U u ^ j y i y f N U M C O ^ O W - e / ^ y )^ \ jOY^ ^T7^'^2^ r^tX<^g£l-Mî— ^^^"'-^^!^^ . ^ / s . hCSL^ 4 A U J -


^

10. FAMILY VISITATION Parents BSERVATIONS

. Sibling. Therapeutic, Dates



Signature / date


WHITE COPY - CASE FE.E • YELLOW COPY - SUPERVISOR • PINK COPY - CAREGIVER/PROVIDER

^ ^ ' ^

O Center for Emilys igSild Enricliment. lnc

PL4fÊMENT Foster Home

' Shelter Residential Facility

, Group Home Relative Other

/ _ / Date Placed


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 Îf^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 ^

/4ê^K n^c^'cm^-ÂAJM^ 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/iiHÔHrC^f&TCnSma 1977

PLACEMENT y^ Foster Home

Shelter Residential Facility Group Home

^Relative VISIT: ANNOUNCED UNANNOUNCED \/_ Other NAME of COUNSELOR'Yv^ ÔuêirLr^ 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 HîêA.

Relationship Ffd&r

Toy's/Play area y-QO ESCRIB]^ f C l m i h j JlOî^ uy^ (K- fh.ir^^ AMypPyyi- hnyyiY JY? ^ t A / ^ t j J & h ^ ^ ' f l D n \ fAhvî. /-( 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)liÛ.] f ^ppâmA' t ' ^d ' cCeHÛ IJW^JU W ' HOTLINE/LICENSING ndtified ~AA0C

OBSERVATIONS ofCHILD } i JYL A^/ 'ÂiuJ:^ fik^SîCtjC 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 HâltlÔ BejiavioralA/p Substance Abuse>y6/ Academic / Q Developmental AJQ

JytC Follow up Actions, _fhi_ :al HealthAÔ 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'AÔ/L; YIÂAT AJUÂL I tCai lc tÂ- 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/VMÂAAU.5 h> VLpirCiS '^Y-C/\jf' tmufjÂ.ruCi guuCCtA

7. CHILD'S COMMENTS / • (/

8. PROGRESS TOWARDS GOAL M . / l ^ y U YXppâîihZ. 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

"îS®

Center for FamilyS îldFnrifhmpntlnf.

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 jû^^ 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 iûy

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/.] COÎJ'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 AÔ 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^î / . 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^


P kO. FAMILY VISITATION Parents SERVATIONS

. Sibling, Therapeutic,

Signature date

Dates

iCY'X ? M - / . y C ^ cQ-J/kAji- 7ACCCAYA<A oÂitA^ A Sisnatwe / date / Sienature/^ date Signature / date


^y date



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~/Â/ t / ' ) ! ryJne>^ IP CODE

Relationship _ VISIT

/==Â^Hr A^YLYLeyy^::^ ANNOUNCED - . ^ U N A N N O U N C E D

NAME of COUNSELOR fignJ^^Â^ 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 <îYI(?^ Acceptable '''l/KLo Environment Safe for Child .„ A ^ ^ ^ DESCRIBE '

JLU

Sufficient Food

•)<: .aAn o,e_j ',^WAPr^'r .Aôyy-\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^â . O / . ^ J A ' Y Y M J ^ - ^ YkUYe /f^J~^îo^. Âf^<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^

î^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


Detention Order ^-Case Plans Judieial Review Social Study Reports


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/

^/Â<»-®-(^_ 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


Signature ' / date


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


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 Fâs^^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^,ÂMr)AaCUA( /y0iry)Y> ^^.ÂZAZZnâ^ ^//-(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


2. CONDITION of CHILD Healthv ""^j}/) WellNourished JK/A) Behavior Placement Ar ropriate ^^/^tîgQS_ofNe^ct/Abuse / l / ^ e4cjPt<t 05SERVATI0NS o f ' ^ ' " '^ " ^ - ^ ^ «.x) L/ . . Vô

Ml ^LD / A ^ . • c( ÂJY^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: Comprehenîv^/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


tention Order Case Plans_^ Judicial Revie .Phvsiciai . Q\ Last Seen by Doctor QT"/-—- / 0'~7êntal

Day Care Aimual Physicalj^^

Last Visit / Hearing FSPT

/ / Vision / / Developmental,

5. COUNSELOR OBSERVATIONS J lÔ

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_- yÂ^(^^s2z^ q J

[ONS for NEXT VISIT ( A ' l (J ^ 9. FOLLOW UP/RECOMMENDATIONS


Sibling Therapeutic, Dates

Signature date Sighature date


Signatufe '' jJate

SUPERVISORY REVIEW

^Jf//i)jf

CAREGIVER/OTHER Acknowledgement only that Counselor visited


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


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


[). 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&iittruHrctrifiJretiîHcciOT

RLACEMENT Foster Home

. Shelter

. Residential Group Home Relative Other


/ / 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^-eî^ 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 . <Â.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<gXÛgt.^^V

= ^ s = -a:! . q FAHIS/LICENSING notified

K-g f <-. -A_âJL/t g l e i g j J ^ t - ^ -^^ -ê . 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


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 ÂfnT ^ 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^


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


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 IhÂXltvCÎS.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\^^Â

Lt-^fi i y \ ^ : ^

\ ^ \ / s ^ s»^ J ^ £ <?.rf>gL.r"

O { •eôu.^

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--âw^ ? 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


16+

m Relative Caregiver

Assessments: Comprehensive_ lollow up Actions

Mental Health Housing

Behavioral Vocational Domestic Violence

Substance Abuse Academic


Developmental_


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^^-î

'p'<tfL^ ''<tfL^>F'^, ^

ISSUES re: SERVICES

7. CHILD'SCOMMENTS g ? L > i ^ <s; , . s>_^ g >.^.>Cc->.><^"y- ^ <->Mg j 3 , < 3 ^ \ "-"^-^-t ^ ^ ^



Inature date'' ' ' ' Signature CAREGIVER/OTHER COUNSELOR - PI/PS/FC


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


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



SSI

Relative Caregiver isessments: Comprehensive_

Follow up Actions Mental Health

Housing Behavioral

Vocational Domestic Violence Substance Abuse Academic


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


^ ^ 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 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


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 /î2£,l O a

ZIP C O D E j Z ^ i / ^

VISIT: ANNOUN^^D ÛNANNOUNCED

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 xê, * ^

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



SSI

ssessments: Comprehensive_ Follow up Actions



Developmental_

Current Reviewed & Birth Certificate.

Day Care Last seen by Doctor

Developmental


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 ,



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


-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.Ô»^<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."ÊRVICES 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


Behavioral Domestic Violence



Developmental_



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_ tOAaQû.v.£^ jar"". S?^*-^ ^-^^^

8. PROGRESS TOWARPS GOAL


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


PATE OfVISIT - ^ ^ ^ - ~ C > 7 NEXT COURT PATE NAME of CHILP POBNAME/APDRESS ofPLACEMENT C/bZLfUgrM

Relationship ô<-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


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


Exit Interviews _ _ Developmental_



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^ÊLATIVE/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- \ - ^



m. FAMILY VISITATION Parents BSERiÂTIONS

Siblings Therapeutic_ Dates

I Sighature CAREGIVER/OTHER


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:î-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-eJAjaÂ>( 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



SSI

Relative Caregiver Âssessments: Comprehensive_ rFollow up Actions


Behavioral Vocational Domestic Violence



Developmental_

/ /



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<»VÂ.-er-\ w g ^ -^3»';V<Hf^ ^ ± FOSTER PARENT/SHELTER/RELATIVE/SCHOOL/PROVIDEK COMMENTS DERCC

^ ^ — ^ ISSUES re: SERVICES

7. CHILD'S COMMENTS , ^ CJU.yj^ ^r,Â. -U^ .J i ^ - ^ ( . ^ IS> g j - . " ^

t v ^v - t ^ ^ " \ : ^ c . ^ < ^ ^ - 7 ^



l tO. FAMILY VISITATION Parents OBSERVATIONi

. Siblings Therapeutic_ Dates

/Sigrfatiu-e date " ' Signature date' Signatun JGIVER/OTHER COUNSELOR - PI/PS/FC SUPERVISORY REVIE


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


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



SSI

Pregnancy Services 16+ Vocational Domestic Violence

(Assessments: Comprehensive_ Follow up Actions



Developmental_


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 ^ ^ - ^



lie. FAMILY VISITATION Parents. OBSERVATIONS

Siblings _ Therapeutic

I Sienature

Dates

Signature date :AREGIVER/OTHER


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


/ / 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-îg-^ 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 .^ jri3îg,'=^ 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

Grade Day Care_ Dental , Hearing Vision

Clothing _ Tutoring Parenting Classes FDLRS Pevelopmental: Early Intervention (0-5) Substance Abuse Newbom

Independent Living: Assessment Curriculum Plan Pregnancy Services 16+ _ Economic Services Relative Caregiver Housing Vocational Domestic Violence



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


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^-Û-~ ^ 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



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


PATE OfVISIT W ' - ' I S ' ^ ^ ^ NEXT COURT PATE NAME of CHILPNAME/APPRESS ofPLACEMENT CCKJÎAA e/v^

, ZIP CODE Relationship

VISIT:

po>^>"^^^ûAj;^ UNANNOUNCED ANNOUNCED _

NAME of COUNSELOR L ^ Q - f e p f - ]lf;>ndi/UÊL 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 _



Pregnancy Services 16+ Vocational

^^^ssessments: Comprehensive f | | ^ o l I o w up Actions C X V A 4 < ^

Mental Health ^Behavioral Domestic Violence

Substance Abuse _Acadei •V>h=J _Î-J_

Academic

^ r


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


Last seen by Doctor / / Developmental

5. COUNSELOR OBSERVATIONS d J u -" -^—^ y - - -

6. FOOTER PARENT/SÎESTER/F

Case Manager

JL. <sa-f-p

fER PARENT/SHmiTER/RELATIVE/SCHOOL/PROVIDER CQMMENTS

C>~>-^Q\ .OCJ[A~\ V r ^ <^

-^^•^\J< ( f t?^ ! z ^ ISSUES re: SERVICES

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^



, 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

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VISITATION REPORT SUMMARY /«ryiiK.iotirCf;if^rtimo: 1977

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PLACEMENT Foster Home Shelter


/ _ / _ 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

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UNIT NARRATIVE

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FAMILY VISITATION Parents JSERVATIONS

Therapeutic_ Dates



Signature / date

SUPERVISORY REVIEW CAREGIVER/OTHER Acknowledgement only tbat Coun'selor visited


(enter for fiamily S ( i d Enrichment, Inc

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c/ier«/jrrujOMr Oplincn Since HJ77 - dcf.state.fl.us · EXPLAIN OBSERVATIONS/INFORMATION in the...

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