Georgia Foster Care Needs Assessment

Contracted Services Review Instrument

General Provider Information

Unique Identifier:______

Agency Name:______

Facility/Family Name:______

Facility Type:Foster homeResidential/institutional care

Therapeutic foster homeEmergency shelter

Group homeRespite services

Therapeutic group homeOther (specify) ______

Capacity / Preferences

Enter the number of bedsfor which the provider has the capacity to provide services. Note that the totals for each sub-group should add to the total capacity of the facility.

The “number of beds” field pertains to the capacity available for children entering placement.

Sub-Group / Characteristic / # Beds
Total Beds Available
By Gender
Male
Female
No Distinction
By Age
Age __ to __
Age __ to __
Age __ to __
Age __ to __
Age __ to __
No Distinction

Populations Targeted for Services

Check the characteristics of the children that the facility targets for service delivery.

Sibling Group:

 Yes If yes, #: _____

 No

Other Special Needs: (check all that apply)

Medically fragile Drug or Alcohol Dependence

Other physical health condition Delinquency

Developmentally delayed Sexual predator

Mental and/or emotional disorder Violent behavior

Sexual Promiscuity Other Behavior problems

 Other (specify) ______

Restrictions

Identify client factors which the provider will not accept (check all that apply).

Medically fragile Drug or Alcohol Dependence

Other physical health condition Delinquency

Developmentally delayed Sexual predator

Mental and/or emotional disorder Violent behavior

Sexual Promiscuity Other Behavior problems

 Other (specify) ______

Rates/Reimbursement

Record the rates of service the agency is reimbursed based on level of care.

Level 1 $______Level 4 $______

Level 2 $______Level 5 $______

Level 3 $______Level 6 $______

Is the provider eligible to receive Medicaid reimbursement for services to children under its own Medicaid number?

 Yes

 No

Services Provided

Check each of the services the agency provides to children.

Basic care Group therapy

Case management Family Therapy

Counseling Psychiatric assessment

Individual therapy Intensive Medical Care

Vision/hearing treatment Education / Head Start

72-hour physical Other Service: ______

Check each of the services the agency provides to families of children placed with the agency.

Case management Psychiatric assessment

Counseling Substance abuse treatment

Individual therapy Substance abuse assessment/screening

Group therapy Wraparound Services

Family therapy Vocational / Job Training

Parenting Classes Other (specify)

GED / Education

Hornby Zeller Associates, Inc.