Exhibit VIII Discharge Summary.doc
DOC document 60 KB Posted
- Attached to
- AZ|CTR078811
- Contract number
- CTR078811
- Issued by
- Arizona
About this file
This document is a Discharge Summary form from the Arizona Department of Child Safety (DCS), located in Phoenix, Arizona. The form is specifically designed to document the discharge details of a child from a group home or placement facility, with comprehensive sections covering the child's educational, health, behavioral, and emotional status at the time of discharge.
While the document does not represent a traditional contract or procurement document, it serves as an administrative record for tracking a child's placement and transition out of a child welfare system placement. The form includes detailed sections for recording the child's personal information, placement type, reason for discharge, educational background, health conditions, behavioral characteristics, medications, and progress toward service plan goals. The document appears to be a standard reporting mechanism used by the Arizona Department of Child Safety to maintain comprehensive records of children in state custody or care.
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Text version
Exhibit IX State of Arizona
Department of Child Safety
Office of Procurement
3003 N. Central St, 20th Fl.
Phoenix, AZ 85012
DISCHARGE SUMMARY
Part A: CHILD
Child’s name (Last, First MI): ____________________________________________________
Participant ID#: ____________________ Adjudicated delinquent: __Yes __ No
Case Plan: ___________________________________ __ AOC __ADJC
Part B: INFORMATION ON PLACEMENT/DISCHARGE Date of Admission: __________________ Date of Discharge: _______________
Discharged From (Name of Facility): _________________________________________________
Address _____________________________________________________
Type of current placement: Group Home
Reason for Discharge:
__ AWOL __ FH __ GH __ Kinship Care __ Return Home __ Detention
__ Hospital __ Other _________________________ Disruption ___Yes ___No TDM Held? Y or N Date:________ CFT Held? Y or N Date: __________
Part C: INFORMATION ABOUT THE CHILD
EDUCATIONAL:
Currently attending school: __Yes __ No
Name of last school attended: ___________________________________________________
Address (No. street, City, State, Zip): ________________________________________________
Phone: _________________ School District: __________________________________
Grade: _________ Special Ed: __Yes __No IEP: __Yes __ No
Comments: __________________________________________________________________
HEALTH / PHYSICAL IMPAIRMENTS / CONDITIONS:
FORMCHECKBOX
Allergies/Asthma
FORMCHECKBOX
Failure to thrive FORMCHECKBOX Sexually transmitted disease
FORMCHECKBOX
Burns FORMCHECKBOX Hearing Deficiency/deafness FORMCHECKBOX Special feeding needs
FORMCHECKBOX
Convulsive Disorder
FORMCHECKBOX
Heart & lung disorders/apnea
FORMCHECKBOX
Speech Disorder
FORMCHECKBOX
Chronic illness
FORMCHECKBOX
HIV/AIDS FORMCHECKBOX
Substance exposed
FORMCHECKBOX
Diabetes FORMCHECKBOX Hyperactivity FORMCHECKBOX Visual impairment
FORMCHECKBOX
Physical handicaps/challenges
FORMCHECKBOX
Premature birth
FORMCHECKBOX
LD, MMR, ED
FORMCHECKBOX
Developmental Disability (autism, Cerebral Palsy, Epilepsy, Mental Retardation)
FORMCHECKBOX
Other
Comments:
BEHAVIORAL / EMOTIONAL / PSYCHOLOGICAL / PSYCHIATRIC:
FORMCHECKBOX
Abusive to Animals
FORMCHECKBOX
Gang Associations
FORMCHECKBOX
Requires considerable supervision & structure
FORMCHECKBOX
Abusive to self
FORMCHECKBOX
Hyperactive
FORMCHECKBOX
Requires therapy on a regular basis
FORMCHECKBOX
Immature
FORMCHECKBOX
Runaway
FORMCHECKBOX
Eating disorder(hazards, sneaks, over eats, poor eater)
FORMCHECKBOX
Temper tantrum
FORMCHECKBOX
Documented Fire setter
FORMCHECKBOX
Sad, angry or withdrawn for extended periods
FORMCHECKBOX
Anxious
FORMCHECKBOX
Sexually active
FORMCHECKBOX
Incorrigible/delinquent
FORMCHECKBOX
Encopresis/Enuresis
FORMCHECKBOX
Smokes cigarettes
FORMCHECKBOX
Destructive to property
FORMCHECKBOX
Clinging
FORMCHECKBOX
Lies excessively
FORMCHECKBOX
Specific DSM IV Diagnosis
FORMCHECKBOX
Defiant
FORMCHECKBOX
Manipulative
FORMCHECKBOX
Drug/substance use/abuse
FORMCHECKBOX
Depressed (diagnosed)
FORMCHECKBOX
Masturbates excessively
FORMCHECKBOX
Unable to relate to peers
Current Medications (type, dosage, duration):
TYPE DOSAGE DURATION
Therapy Issues:
SPECIAL INSTRUCTIONS / SUMMARY:
(Any future appointments, extra transportation, current therapist, history of sex abuse as victim/perpetrator, needs requiring further explanation or not previously addressed):
PART D: BRIEF SUMMARY OF PROGRESS TOWARD SERVICE PLAN GOALS
PART E: SIGNATURES
Authorized Group Home Staff/Resource Parent Signature: _____________________________________
Date: ______________ Time: ______________
ADCS Rep Signature: ______________________________________ Date: _______ Time: _______
Copy of Discharge Packet given to: (Signature) ____________________________________
(Print Name) ___________________________ Date: _______ Time: _______ If child is absent without leave (AWOLED), what happened to belongings?
__ Child took belongings
__ Belongings inventoried, bagged and tied. Group Home will hold for one month
__ Case manager/designee picked up belongings on ___________ Comments:
Attachments:
__ Copy of Emergency Admission Form Incident Reports on child Updated PS-020 on child
__ Other ____________________ 08/10/2016
File details come from the government source that posted it. Updated .