Child and Adolescent Needs and Strengths Summary Instructions
This form contains 56 fields organized into 15 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Caseworker Information | ||
| Caseworker Name | Text |
Please provide the full name of the caseworker.
|
| Caseworker Phone Number | Text |
Please provide the phone number of the caseworker.
|
| Child Details | ||
| Date of Presentation | Date |
Enter the date of the child's presentation.
|
| Date of Birth | Date |
Enter the child's date of birth.
|
| Age | Text |
Enter the child's current age.
|
| Gender | Text |
Enter the child's gender.
|
| Race/Ethnicity | Text |
Enter the child's race or ethnicity.
|
| Language | Text |
Enter the child's primary language.
|
| Child Identification | ||
| CFS Number | Text |
Enter the CFS (Child and Family Services) identification number.
|
| Child Name | Text |
Enter the full name of the child.
|
| Child ID Number | Text |
Enter the unique identification number assigned to the child.
|
| R/S/F Status | Text |
Enter the R/S/F (Race, Sex, Foster/Residential Status, etc.) code or status for the child.
|
| Clinical Status | ||
| Current Placement | Text |
Provide the current placement of the child.
|
| Length of Stay | Text |
Enter the total duration of the child's current stay.
|
| Most Current IQ | Number |
Provide the child's most recently recorded intelligence quotient (IQ) score.
|
| Anticipated Discharge Date | Date |
Enter the expected date of discharge for the child.
|
| Diagnosis | ||
| Diagnosis 1 | Text |
Please provide the first diagnosis for the child.
|
| Diagnosis 2 | Text |
Please provide the second diagnosis for the child.
|
| Diagnosis 3 | Text |
Please provide the third diagnosis for the child.
|
| Educational Summary | ||
| Text | ||
| Emotional/Behavioral Needs | ||
| Emotional and Behavioral Needs | Text |
Please provide a detailed description of the child's emotional and behavioral needs.
|
| Family Involvement | ||
| Family Involvement Details | Text |
Provide a detailed description of the family involvement, including information about parent and sibling visitation.
|
| General | ||
| TPR Yes | Checkbox |
Check this box if Parental Rights are terminated for the child.
|
| TPR No | Checkbox |
Check this box if Parental Rights are not terminated for the child.
|
| Sexual Behavior Problems Yes | Checkbox |
Check this box if the child exhibits sexual behavior problems.
|
| Sexual Behavior Problems No | Checkbox |
Check this box if the child does not exhibit sexual behavior problems.
|
| Text12 | Text | |
| Text13 | Text | |
| Text24 | Text | |
| Text25 | Text | |
| Text26 | Text | |
| Text27 | Text | |
| Text28 | Text | |
| Text29 | Text | |
| Text30 | Text | |
| Text31 | Text | |
| Text32 | Text | |
| Text33 | Text | |
| Text34 | Text | |
| Text35 | Text | |
| Text36 | Text | |
| Text37 | Text | |
| Text38 | Text | |
| Text39 | Text | |
| Text40 | Text | |
| Text41 | Text | |
| Medical Needs | ||
| Medical Needs Description | Text |
Provide a detailed description of the child's medical needs.
|
| Medications | ||
| Medication 1 | Text |
Provide the name of the first medication.
|
| Medication 2 | Text |
Provide the name of the second medication.
|
| Medication 3 | Text |
Provide the name of the third medication.
|
| Permanency Goal | ||
| Text11 | Text | |
| Permanency Goal | Text |
Enter the permanency goal for the child.
|
| Service Needs Upon Discharge | ||
| Service Needs Upon Discharge Details | Text |
Provide a detailed description of the services required or recommended for the child upon their discharge.
|
| Supervisor Information | ||
| Supervisor Name | Text |
Provide the full name of the supervisor.
|
| Supervisor Phone Number | Text |
Provide the phone number of the supervisor.
|
| Youth's Strengths, Interests, and Hobbies | ||
| Text | ||