Foster Care Open Clients Checklist

Person responsible for the chart

Section 1 Consumer Information

Emergency Contact Information Authorization to Obtain Routine & Emergency Medical Care RLS 3
Application for Services (RLS 1)
Placement Agreement (RLS 2)
Individual Water Hazard Safety Plan (DSS-5018) completed within 48hrs of placement (only needed if the placement has a body of water)
Birth Certificate
Medicaid card
Social Security Card
Court Dispositions non-secure custody order (if child is in custody of someone other than biological parents)
Current Medical Exam (DSS-5209)
Medical Exam completed within 1 week of placement (DSS-5208)
Dental Exam completed within 1 year of placement or within 6 weeks if they haven't been going to the dentist before care
Immunization Records (from NC Immunization Registry)
Psychological, psychiatric reports, and Comprehensive clinical assessment
Documentation of MI/DD/SA as in DSM-IV
Screening and Assessments
Intake Study (included in Application RLS 1)
Out of Home Family Services agreement (DSS-5240) within 1st 30-days (DSS Custody)
Out of Home Family Services agreement (DSS-5240) reviewed within 60-days
Out of Home Family Services agreement (DSS-5240) reviewed within 90-days of 1st review
Out of Home Family Services agreement (DSS-5240) every 6 months thereafter
PCP (with Signatures)
Documentation of need to place a child beyond 150 mile radius of CPA and/or child's parents
Permission for Administering Non-Prescription Medication
Consent for Release of Confidential Information (DSS-5297)
Overnight Travel/Other Travel (RLS 28)
Audio/visual release (signed by the guardian, if the child is over the age of 12 they must sign too)
Educations Assessments
Signed Visitation & Contact Plan (DSS-5242)
Documentation of searches
Discharge Summary