Clinic Check in:
Please fill out the following prior to your appointment at the clinic. This will help us provide excellent care.
County requesting appointment? *
Caseworker Name: *
Your answer
Caseworker Email (to receive records): *
Your answer
Foster parent/Group Home Name: *
Your answer
Foster parent/Group contact information:
Your answer
Foster Child's Name: *
Your answer
Foster Child's DOB: *
MM
/
DD
/
YYYY
Reason the child came into care: *
What was the date of the 72 hour hearing? We try to see all the new children within 5 days of the 72 hour hearing to initiate services. *
MM
/
DD
/
YYYY
Foster Child's Amerigroup Number (if available): *
Your answer
Services Needed: *
Yes
No
Well Check (school forms provided)
Physical- sports
Dental
Psychological
Trauma Assessment
Therapy
Psychiatric Services
IEP/504/SNP assistance
Hair service (charges DFCS rates)
Lice Treatment (would need to bill to DFCS)
Would you like an overview for Children's court?
Do you have birth records?
Exposed to drugs?
Abuse we should be aware of ?
If you do not have birth records do you know where they were born? *
Your answer
If the child is on any medications please list diagnosis & medication below: (please list who prescribed the medication if possible) *
Your answer
Any food or drug allergies: *
Your answer
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