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Host Family Home - Youth's Record Form 7.721. ...
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Facility Name:ID# CDHS Staff Date :
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Child's Name .952C1DOB DOE .952C1 Place of Birth Gender Race
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Admission Records /HistoryAuthorizations/ Documenation of attempt to obtain Assessment Other Ongoing Records
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Religious preference .952C1 Authorization for care and treatment .43M2 Assessment w/in 3 days of admission includes : . 43HPsychological /psychiatric reports (if available) .952C2
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Referring agency given copy of written admission policies and criteria .43 Under 18, Obtain verbal permission to serve youth, document attempts to obtain permission .43JSocial, Physical Health, Mental Health . 43HIf no recon. w/in 48 hours & agency anticipates recon taking longer than 21 days, - Provide youth and parents with written statement including : .43L
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Host Family Home qualified and able to meet needs of all youth in care .42C Orientation and Youth's Rights Service/ Transition Plan Availability of counseling services .43L1
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Notifications and Contacts Required at AdmissionPreliminary screening of immediate needs of youth .43HWritten service and transition plan .42 BAvailability of longer term residential arrangements .43L2
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Under 15yrs- Referral to County department of residence of parents w/in 72 hours .42B1 Initial Orientation w/in 24 hours .43K Development of service plan actively involved youth/family/ HFH/ other supports .42B .43M Possibility of referral to county department .43L3
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Over 15 yrs & determined additional services necessary- Referral to county department of residence of parents. .42B2Youth’s Rights and Grievances, Any restrictions documented .51B If above not involved, then documentation as to why .43MRecord of family contacts or contact with other agencies .952C4
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All- MAY Contact county department of residence of parents to check for existing services in place .42B1Medical requirments Case plan include by reference or attachment: .43MArrange transportation to parent’s home when approp. .43 I 3-4
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Youth 11-15 yrs & youth returns to HFH second time after 21 days – Referral to county department of residence of parents. .42B3Medical/health reports .952C3 Youth and parent/guardian expectations of family contact and involvement .43M1Discharge Records
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Notify parent/guardian of youth’s : 43I1Medication summary/ Reports / list of current medications .952C3 .91F2How family contact and involvement will occur , nature and goals of care .43M1Discharge includes .952 D
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Whereabouts . 43I1 Referral to health care if needed .31A Specialized services or treatment to be provided .43M1Date of discharge or removal .952D1
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: Physical condition, . 43I1 Youth referred to specialist for further assessment or treatment .981B (medical or mental health) Religious orientation and practices of the HFH .43M1Plan for the youth .952D2
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 Emotional condition . 43I1 Written physician authorization for prescribed meds .91 F 4 Education opportunities .81 Circumstances that lead to unplanned discharge .952D3
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Circumstance surrounding placement .43I1Written authorization from physician for non-prescriptive medications .91F 5 (OTC) Under 18 may get verbal followed by written authorization .91F6Community participation opportunities .82 Case manager authorization for work or volunteerAnticipated discharge date .43M1
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Notify parent/guardian of intent to reunify youth/ family and alternatives available .43I2 Medication logs .91 F7 Written documentation details implementation of service plan .42B3Plan following discharge .43M1
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Special diets due to allergy, religious belief, other .921F.
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