(To use Forms........ Copy and Cut into Word Document  & Print as needed)

FOSTER CHILD’S INFORMATION LOG:

Child’s Name:
Birth Date:
Social Security #:
Date of Placement:
Child Arrived With:
Medication:
Allergies:
Sensitivities:
Lice:
Medicaid #
Immunization Record Received:
Dr’s Visit (Name/date)
Dr.’s Address/Phone
Dentist Visit (date)
Dentist Name, address, phone
Counseling date
Counselor name, address, phone
Reason for Removal:
Acting out issues:
Siblings:  Name & Location

FOSTER CHILD’S INFORMATION LOG, CONTINUED:

Caseworker Name
Caseworker Phone #
Beeper/Cell Phone #
Office Address/ phone
Supervisor Name/Phone
Attorney ad Litem Name, address, phone
CASA name, address, phone, supervisor
Prior School(s) – name, address
Grade
Learning Challenges
New School, phone, address, teacher
Visit Information – date, time, location, staff member who will supervise & phone number
Removal Date:
Show Cause Hearing Date: (14 days after removal)
PPT #1
Status Review Hearing
Permanency Hearing
Date Left Foster Home
Left to Live With:
Items Sent with Foster Child

MEDICAL EXAMINATION FORM (SICK CHILD)

Name of Doctor:     ______________________________________

Address:                ______________________________________

                             ______________________________________

Phone Number:      ______________________________________

Child’s Name:         ______________________________________

Date of Exam:         ______________________________________

Initial Complaints:  

Findings:

Treatment Provided Today:

Recommended Follow-Up:

____________________________________                      ________________

    Signature                                                                     Date