Attachment D: Universal Application - For Information Only.pdf

ATTACHMENT D UNIVERSAL APPLICATION – FOR INFORMATION ONLY

DSS Form 30148 (July 2020) Page 1 of 11

Universal Application

GENERAL AND DEMOGRAPHIC INFORMATION

Case ID:

Child’s Name: DOB & Age:

SSN:

Race: Hispanic Ethnicity: Sex:

Primary Language: Child's Height: Child’s Weight:

Eye Color: Hair Color: Identifying Marks or Tattoos:

Immigration Status: Is the child ICWA eligible?

□ Yes □ No

Tribal Affiliation:

Medicaid #: Medicaid Program: Third Party Insurance:

Pregnant or Parenting Youth:

□ Yes □ No

If Parenting, provide location of the child:

Dietary Restrictions/Alerts:

Reason child entered foster care:

Has this child been adopted?

□ Yes □ No

Is this a post-legal adoptive placement?

□ Yes □ No

PLACEMENT NEED

□ Initial Placement □ Change in Placement County of Origin:

Legal Auth. for Initial Placement: Current Placement Type: Current Level of Care:

Placement Alert: Placement Change Reason:

Placement Type/Level Needed: Date Placement Needed:

CHILD CHARACTERISTICS

Child Strengths/Protective Factors:

□ Confident □ Strong Familial Attachments

□ Extracurricular Activities □ Problem Solving Skills/Critical Thinker

□ Cultural Identity □ Spirituality

□ Genuine Interest in School □ Talents/Interests

□ Goal-setter □ Trustworthy

□ Hobbies □ Strong Community Attachment

□ Resilient □ Strong Social Connections

□ Initiative and Personal Drive (Please Specify) □ Other (Please specify)

□ Sense of Purpose/Positive Outlook

Hobbies: Talents/Interests: Social Connections:

DSS Form 30148 (July 2020) Page 2 of 11

PLACEMENT HISTORY

# Placement Type Level of Care Provider Start Date End Date Termination Reason

FAMILY MEMBERS/SIBLINGS IN FOSTER CARE

Any family members/siblings in Foster Care?

□ Yes □ No

# Family Member Name: Relationship

PLACEMENT HISTORY FOR:

# Placement Type Level of Care Provider Start Date End Date Termination Reason

Any placement restrictions including sibling placement?

If yes, please indicate the restrictions:

DSS Form 30148 (July 2020) Page 3 of 11

SOCIOCULTURAL FACTORS

Religious/Spiritual Identification:

Are there any special considerations/ practices to consider?

Does the child identify as LGBTQI? If yes, specify what the child identifies as: Preferred Proper Pronoun:

If yes, are there any concerns for the placement to be aware of? Please explain:

DSS Form 30148 (July 2020) Page 4 of 11

MEDICAL HEALTH

Child’s Primary Care Provider: Child’s Dental Provider: Child’s Vision Provider:

Immunization Record?

# Immunization Immunization Date Provider Name Dosage Refused

Does the child have a diagnosable medical condition?

# Diagnosis Category Diagnosis Type Provider Name Start Date End Date

Additional Medical Diagnosis Details:

Allergies?

□ Yes □ No Current Medications?

# Medication Name Dosage Strength Frequency Provider Name Dosage Instructions

Will foster parent/placement receive medications?

If yes, how much will be given:

If no, and child has a prescription, please explain:

DSS Form 30148 (July 2020) Page 5 of 11

HEALTH HISTORY

# Health Condition No Yes Past Unknown Explanation

1 Anemia/Blood Disorder 2 Anesthesia Problems 3 Asthma 4 Autism Spectrum Disorder 5 Bedwetting 6 Birth Defects 7 Cancer 8 Cerebral Palsy 9 Dental Problems

10 Developmental Delay 11 Diabetes 12 Epilepsy/Seizures 13 GI Problems 14 Head Injuries 15 Hearing Problems 16 Heart Murmur 17 Heart Problems 18 High Blood Pressure 19 Incontinence 20 Intellectual Disability 21 Learning Disability 22 Other 23 Physical Disabilities 24 Sickle Cell Disease 25 Skin Problems 26 Tuberculosis (TB) 27 Vision Problems

Special Needs/Disabilities:

Special Medical Equipment/Devices?

□ Yes □ No

Has the child ever been hospitalized?

□ Yes □ No

If yes, why and where was the child hospitalized?

Does the caregiver require special training to support the child’s special needs or training related to the special medical?

Equipment? If so, please explain:

DSS Form 30148 (July 2020) Page 6 of 11

MENTAL/BEHAVIORAL HEALTH

Does the child have a diagnosable mental health condition?

# Diagnosis Category Diagnosis Type Provider Name Start Date End Date

Has the child received a diagnostic assessment or psychological evaluation in the last 12 months?

If yes, what diagnoses were identified?

Is the child currently receiving any behavioral or mental health services?

□ Yes □ No

If yes, please provide details and contact information for the provider:

Does the child have a history of, or suspicion, of being a victim of human trafficking?

If yes, what special considerations should be given regarding placement, restrictions, and safety concerns?

TRAUMA SCREENING

Check if known history of abuse/ACES

□ Neglect □ Extreme Interpersonal Violence

□ Physical Assault/Abuse □ Traumatic Loss/Separation

□ Sexual Assault/Abuse □ Medical Trauma/Extended Illness

□ Emotional Abuse □ Serious Injury

□ Domestic Violence □Caretaker Absence/Incapacity (AOD, MH, Med)

□ Community Violence □ Natural Disaster

Has the child ever received any services specifically related to their trauma?

□ Yes □ No

Has a forensic interview been conducted?

□ Yes □ No

If yes for either, please describe

Comments/Additional Information

DSS Form 30148 (July 2020) Page 7 of 11

SYMPTOMS/BEHAVIORS

# Symptom/Behavior No 0-30 Days

30 Days To 1 Year

1 Year and more

Unknown Description

1 Attention Deficit Disorder (ADD) □ □ □ □ □

Attention Deficit/Hyperactivity Disorder (ADHD)

3 Animal Cruelty □ □ □ □ □

4 Animal Fear □ □ □ □ □

5 Anxiety □ □ □ □ □

6 Attachment Problems □ □ □ □ □

7 Attempted Suicide □ □ □ □ □

8 Attention Problems □ □ □ □ □

9 Property Damage □ □ □ □ □

10 Depression □ □ □ □ □

11 Eating Disorder □ □ □ □ □

12 Encopresis □ □ □ □ □

13 Enuresis □ □ □ □ □

14 Excessive Hyperactivity □ □ □ □ □

15 Extreme Attention Seeking □ □ □ □ □

16 Fire-Setting □ □ □ □ □

17 Gang Involvement □ □ □ □ □

18 Habitual Lying □ □ □ □ □

19 Hoarding □ □ □ □ □

20 Homicidal Thoughts □ □ □ □ □

21 Intense Anger □ □ □ □ □

22 Negative Peer Association □ □ □ □ □

23 Oppositional □ □ □ □ □

Other Mental Health/Behavioral Problems

25 Physical Aggression □ □ □ □ □

26 Requires Constant Supervision □ □ □ □ □

27 Runaway □ □ □ □ □

28 School Difficulties □ □ □ □ □

29 Hallucinations □ □ □ □ □

30 Self-injurious behavior/self-Harm □ □ □ □ □

DSS Form 30148 (July 2020) Page 8 of 11

31 Sexual Aggression □ □ □ □ □

32 Sexual Inappropriateness □ □ □ □ □

33 Sleep Difficulty □ □ □ □ □

34 Stealing □ □ □ □ □

35 Stool Smearing □ □ □ □ □

36 Substance Use □ □ □ □ □

37 Suicidal Thoughts □ □ □ □ □

38 Verbal Aggression □ □ □ □ □

DSS Form 30148 (July 2020) Page 9 of 11

EDUCATION

Home School District: Current School:

Current Grade Level: On Grade Level?

□ Above Grade □ At Grade □ Below Grade □ Special Education

Other: □ GED Preparation □ Homeschooled □ Psychoeducational Assessment

Does the child have an IEP?

Does the child have a 504 Plan?

□ Yes □ No

If yes, name the disability and/or any required accommodations:

Yes No Unknown

Currently Expelled/Suspended

History of Expulsions/Suspensions

Alternative School Placement

History of Skipping School or Truancy

Extracurricular Activities:

LEGAL INVOLVEMENT/HISTORY

Child Parent/Caregiver

□ Department of Juvenile Justice

□ Department of Corrections

□ Probation/Parole Officer

□ Pending Charges

□ Pending Court Date

□ Detention/Evaluation Placement History □ Adjudicated

□ Convicted

□ Victim of Crime

□ Other (Provide Details)

□ Department of Juvenile Justice

□ Department of Corrections

□ Probation/Parole Officer

□ Pending Charges

□ Pending Court Date

□ Detention/Evaluation Placement History

□ Adjudicated

□ Convicted

□ Victim of Crime

□ Other (Provide Details)

Probation/Parole Officer: Probation/Parole Officer:

Pending Charges: Pending Charges:

Pending Court Date: Pending Court Date:

Comments/Additional Information:

PERMANENCY GOAL & VISITATION

What is the child’s primary permanency goal? What is the child’s concurrent permanency goal?

Has a visitation plan been established for this child?

# Plan Type Member Name Frequency Location Start Time End Time

DSS Form 30148 (July 2020) Page 10 of 11

Are there any restrictions or limitations for visitation?

DSS Form 30148 (July 2020) Page 11 of 11

CASE MANAGER CONTACT INFORMATION

County: Office Address:

Case Manager: Telephone Number: Cell Phone Number: Email:

Case Manager’s Supervisor: Telephone Number: Cell Phone Number: Email:

Emergency Contact Number: After-Hours Contact Number: