Distribution: Foster Home File, Child/Youth S Record, Private Providerrda 2877
Placement Checklist
Youth’s Name / Level / 1 2 3 Unknown
DOB/Age / Security Number / Gender / Male Female
NewPlacement
Grade Level/School
Foster parents have a right to information regarding the children placed in their care. The information provided below is in compliance with Tennessee Code 37-2-415. This information is provided to the foster parent at the time of the youth’s placement and consists of pertinent information available to the Department at the time of placement.
The youth was placed in custody of the Department of Children’s Services due to the following:Dependent/Neglect / Unruly / Delinquency
Please give a brief description:
Youth Risk Behaviors:
Danger to Others Yes No / Sexual Aggression Yes No / Sexual Reactive Yes No
Fire Setting Yes No / Suicide Risk Yes No / Self-Mutilation Yes No
Other Self-Harm Yes No / Runaway Yes No
Substance Abuse: Alcohol Use Illegal Drugs Prescription Drugs Tobacco Use
MUST provide explanation (when, where, frequency, approximate date of last occurrence, etc.) for any answer marked “Yes”.
Other Behavioral/Emotional Factors:
Bedwetting Yes No / Constant Supervision Required Yes No / Cruel to Animals Yes No
Fear of Animals Yes No / Extreme Attention Seeking Yes No / Habitual Lying Yes No
Intense Anger Yes No / Makes False Statements Yes No / Stool Smearing Yes No
Oppositional Yes No / School Difficulties Yes No / Burglary/Theft Yes No
Negative Peer Association Yes No / Vandalism/Destruction of Property Yes No
MUST provide explanation (when, where, frequency, approximate date of last occurrence, etc.) for any answer marked “Yes”.
Legal Charges:
Pending:
Adjudicated:
MUST provide explanation for any pending or adjudicated charges.
Physical Disabilities:
Does the youth have any physical disabilities or special needs? Yes No
If Yes, please specify:
Developmental:
Does the youth have any developmental disabilities? Yes No
If Yes, please specify:
Mental Health:
Does the youth have any mental health or behavioral issues? Yes No
If Yes, please specify:
Medical:
Does the youth have any medical issues? Yes No
If Yes, please specify:
Current Medications:
Is youth currently on any medications? Yes No
If so, list all prescriptions and over the counter medications including dosage and frequency:
New foster placement has received youth’s medication Yes No
If not, please explain why and describe the plan to obtain needed medication:
Allergies:
Medication:
Food:
Insect Stings:
Other:
Additional Information
Is the minor female pregnant? Yes No
Is the minor parent of a youth/infant? Yes No
If yes, is the youth in the custody of the Department of Children’s Services? Yes No
DCS / Provider Staff / Date
Foster Parent / Date
Foster Parent / Date
Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.
Distribution: Foster Home File, Child/Youth’s Record, Private ProviderRDA 2877
CS-0544 Page 1
Rev. (08/17)