Exhibit XV Discharge Summary.pdf

Exhibit XV (05/24)

CONGREGATE CARE

DISCHARGE SUMMARY

ARIZONA DEPARTMENT OF CHILD SAFETY

Date of Birth

Child Information

Child's Name (Last, First MI): Participant ID No.:

Case Plan

Education

Health/Physical Impairments/Conditions:

Behavioral/Emotional/Psychological/Psychiatric:

Name of current/last school attended Phone

Is the child currently attending school?

Comments:

Special Ed:

IEP

Yes

Yes

Yes

No

No

No

Adjudicated Delinquent Yes No

Allergies/Asthma Burns Convulsive Disorder

Abusive to Animals Gang Associations Requires considerable supervision & structure

Sexually transmitted disease Special feeding needs Speech Disorder

Sad, angry or withdrawn for extended periodsImmature Runaway

HIV/AIDS Hyperactivity Premature birth

Destructive to propertyAnxious Sexually active

Failure to thrive Hearing Deficiency/deafness Heart & lung disorders/apnea

Abusive to self Hyperactive Requires therapy on a regular basis

Chronic illness Diabetes Physical handicaps/challenge

Temper tantrum Documented Fire setter Incorrigible/delinquent

Substance exposed Visual impairment LD, MMR, ED

Encopresis/Enuresis Smokes cigarettes Specific DSM IV Diagnosis

Defiant Unable to relate to peersManipulative

Developmental Disability (autism, Cerebral Palsy, Epilepsy, Mental Retardation) Not Listed

Lies excessivelyClinging Drug/substance use/abuse

Depressed (diagnosed) Masturbates excessively Eating disorder (hazards, sneaks, over eats, poor eater)

City State Zip Code

Grade

Address

CONGREGATE CARE

DISCHARGE SUMMARY

ARIZONA DEPARTMENT OF CHILD SAFETYExhibit VI (05/24)

Emergent Disruption?

TDM Held?

CFT Held?

Discharged From (Name of Agency and Facility)

Date

Date

City State Zip Code

Date of DischargeDate of Admission

Information On Placement/Discharge

Address

Reason

Reason

Type of current placement

Reason for Discharge

Group Care with Specialty

FH

Return Home

Intensive Shelter Care

GH Hospital

Detention Not Listed

Group Care

AWOL

Kinship Care

Yes

Yes

Yes

No

No

No

Child Information ~continued

Current Medications (type, dosage, duration should be sent with child)

Therapy Needs

CONGREGATE CARE

DISCHARGE SUMMARY

ARIZONA DEPARTMENT OF CHILD SAFETYExhibit VI (05/24)

Signatures

Date

Authorized Group Home Staff or Resource Parent (Print Name)

Child's Name (if child is 12 years old or older)

ADCS Representative Name (Print Name)

ADCS Representative Name (Print Name)

Authorized Group Home Staff or Resource Parent Signature

Child's Signature (if child is 12 years old or older)

ADCS Representative Signature

ADCS Representative Signature

Date

Date

Date

Date

Any future and standing appointments, extra transportation, current therapist, history of sex abuse as victim/perpetrator, needs requiring further explanation or not previously addressed.

Special Instructions/Summary

Brief Summary of Progress Toward Service Plan Goals

Belongings

Comments:

Copy of Discharge Packet given to:

Child took belongings

Copy of Emergency Admission Form Incident Reports on child Updated PS-020 on child

Self-Dislosed:

Case manager/designee picked up belongings on:

Belongings are inventoried, packed in appropriate suitcase(s) or duffel bag(s). Group Home shall hold for one (1) month if no documented response if received from the Department

Attachments