Foster Care Open Clients Checklist

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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