Request for Placement
Child’s Name: ________________________Date of Birth: ___________Person ID #______________
Gender: O Male O Female Ethnicity
__________ Age: ______
County
of Legal Conservatorship: ______________ Preferred
Placement Area: ________________
Child’s
religious preference:
_____________________________________________________________
Reason(s)
for removal:
q
Emotional
Abuse_________________________________________________________________
q
Physical Abuse__________________________________________________________________
q
Sexual Abuse____________________________________________________________________
q
Abandonment___________________________________________________________________
q
Neglectful Supervision____________________________________________________________
q
Medical
Neglect_________________________________________________________________
q
Physical Neglect_________________________________________________________________
q
Refusal to Accept Parental Responsibility____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Permanency
Goal:
q Family
Reunification_____________________________________________________________
q Relative
Placement_______________________________________________________________
q Independent
Living_______________________________________________________________
q Adoption_______________________________________________________________________
q
Permanent Managing Conservatorship________________________________________________
Expected
Length of Placement:
q 3 months or
less_________________________________________________________________
q 4 to 6
months___________________________________________________________________
q More than 6 months______________________________________________________________
Frequency of recommended
face-to-face contact between child and family:
q
Weekly________________________________________________________________________
q
Every other week_________________________________________________________________
q
Monthly________________________________________________________________________
q
None__________________________________________________________________________
q
Other__________________________________________________________________________
q Child is not school age.
q Child is school age and is enrolled in the _______ grade at _________________________School.
q Child is school age but not attending school. Please, note reason(s) the child is not attending school: __________________________________________________________________________________________________________________________________________________________________
q Child is currently receiving special education services.
q Child has received special education services in the past.
q Autism_________________________________________________________________________
q Developmental Disability__________________________________________________________
q Learning Disability_______________________________________________________________
q Mental Health (DSM-IV)__________________________________________________________
q Mental Retardation (note FSIQ if known) _____________________________________________
q Primary Medical Needs___________________________________________________________
q
Other__________________________________________________________________________
Special
Services Needed by Child: (check all that apply and explain)
q Awake at night
caregivers_________________________________________________________
q Direct, continuous monitoring _____________________________________________________
q Medically competent caregivers____________________________________________________
q 24 hour medical/nursing support ____________________________________________________
q Activities to meet therapeutic or developmental needs___________________________________
q Medical/physical supports _________________________________________________________
q Assistance with activities of daily living (ADL)_________________________________________
q On Campus school________________________________________________________________
q Individual, group and/or family therapy________________________________________________
q Treatment program designed by interdisciplinary team_____________________________________
q Substance abuse treatment program____________________________________________________
q Therapeutic services to address sexual issues_____________________________________________
q
Other____________________________________________________________________________
Child’s
History/Characteristics Indicating Need for Special Services: (check all that apply and
explain)
q Animal cruelty
Hx_______________________________________________________________
q Destroys
property________________________________________________________________
q Developmental
Delays____________________________________________________________
q Hearing Impaired__________________________________________________________________
q Visually
Impaired__________________________________________________________________
q Encopretic______________________________________________________________________
q Enuretic________________________________________________________________________
q Fire Setting
Hx__________________________________________________________________
q Gang Activity
Hx_________________________________________________________________
q Juvenile Justice
Hx________________________________________________________________
q Multiple
Placements_______________________________________________________________
q Physical limitations
_______________________________________________________________
q Physically aggressive
_____________________________________________________________
q Pregnant/Parenting Teen
___________________________________________________________
q Runs
away______________________________________________________________________
q Self-abusive_____________________________________________________________________
q Sexually abusive, aggressive
or assaultive______________________________________________
q Sexually inappropriate
behavior______________________________________________________
q Sibling(s) in
placement_____________________________________________________________
q Spanish is primary
language________________________________________________________
q Steals_________________________________________________________________________
q Substance use
Hx_________________________________________________________________
q Suicide threats
Hx________________________________________________________________
q Suicide attempts
Hx_______________________________________________________________
q Other___________________________________________________________________________
Additional
information to be considered:
____________________________________________________
________________________________________________________________________________________
Source of information on child: __________________________________________________
--------------------------------------------------------------------------------------------------------------------------------
Issues
to consider in making placement decision:
The child’s needs.
The caregiver’s ability to meet the child’s needs The least restrictive, most
family-like setting available.
Close proximity to child’s home. Placement
with siblings. .
The
child’s or youth’s preferences. The
child’s permanency plan.
Placement(s)
recommended: (list
family based settings first)
______________________________________ ___________________________________
______________________________________ ___________________________________
______________________________________ ___________________________________