Information for Foster Parents

INFORMATION FOR FOSTER PARENTS

PART A

Dear Foster Parent:

RE: [TM1]

The attached forms and information are provided to you according to s. 895.485(4)(a), Wis. Stats., and ch. HFS 37, Adm. Code. We have tried to give you all of the information indicated on the forms, but we often do not have complete information at the time of placement.

Together we are partners in the provision of services for this child. Therefore, we must both try to gather and share information on this child. Add information to this form whenever you gather it; e.g., from the child or his / her family or from a physician. We shall also continue to provide you with information.

During our later visits, we will share with each other any new information that becomes available.

All of the information regarding this foster child provided to you on these forms and in any other manner, is done so with the expectation that you will maintain the information in confidence. State and federal statutes require that this information be kept confidential. If you have any questions regarding what information you may share with any party (e.g., health care providers, schools), please contact the child's social worker.

This first section, Part A, Face Sheet, contains information that is critical for foster parents to know as soon as the child first enters placement. Some of the material is repeated elsewhere in the form.

Note: If the space provided on the form is not adequate, make a note that information is continued on the back or a separate sheet of paper. Clearly indicate which section or item number any supplemental information pertains to.

INFORMATION FOR FOSTER PARENTS - PART A

FACE SHEET

Use of form: The information contained in this form must be provided to the foster parent at the time of placement unless there is no way to gather the information prior to the child's placement. Information not provided at the time of placement must be provided within 48 hours. If additional space is needed when completing this form, attach separate sheet(s).

I.GENERAL INFORMATION (Critical Facts to Know)
Date Form Filled Out (mm/dd/yyyy)
[TM2] / Date Child Placed in Foster Care (mm/dd/yyyy)
[TM3]
A.Child Information
Name - (Full Legal)
[TM4] / Nickname(s)
[TM5]
Birthdate (mm/dd/yyyy)
[TM6] / Gender
[TM7]Female[TM8] Male / Social Security Number
[TM9]
Height
[TM10] / Weight
[TM11] / Religious Belief or Affiliation - Child or Family
[TM12]
B.Parent Information
Name - Mother
[TM13] / Mother is Child's
[TM14] Birth mother [TM15] Stepmother [TM16] Adoptive mother
Address (Street, City, State, Zip Code)
[TM17]
[TM18]
Telephone Number - Home
[TM19] / Telephone Number - Work
[TM20]
Name - Father
[TM21] / Father is Child's
[TM22] Birth father [TM23] Stepfather [TM24] Adoptive father
Address (Street, City, State, Zip Code)
[TM25]
[TM26]
Telephone Number - Home
[TM27] / Telephone Number - Work
[TM28]
C.Placement Reason (Allegation)

[TM29]

[TM30] Yes / [TM31] No / The child was previously in the child welfare system.
[TM32] Yes / [TM33] No / The child was removed from his or her own home.
[TM34] Yes / [TM35] No / The child was removed from another foster home.
D.Emergency Contact Person
Name
[TM36] / Telephone Number
[TM37]
E.Social Worker / Agency / Agency Secondary Contact
Name - Child's Social Worker With Whom Foster Parent Will Have Contact
[TM38] / Telephone Number - Social Worker
[TM39]
Name - Social Worker's Agency (County and/or Region)
[TM40] / Telephone Number - Agency
[TM41]
Name - Agency's Secondary Contact (e.g. supervisor)
[TM42] / Telephone Number - Secondary Contact
Regular Hours / After Hours
[TM43] / [TM44]
F.MA Card
[TM45] Yes / [TM46] No / Has the out-of-home care provider been given the child's MA card (regular or temporary)?
If "No", describe how and when it will be provided.

[TM47]

G.Prohibited Contacts and Visitors
Name
[TM48] / Relationship
[TM49]
Name
[TM50] / Relationship
[TM51]
Name
[TM52] / Relationship
[TM53]
Name
[TM54] / Relationship
[TM55]
Name
[TM56] / Relationship
[TM57]
H.a.Physician - Child's
Name
[TM58] / Telephone Number
[TM59]
b.Mental Health Provider
Name
[TM60] / Telephone Number
[TM61]
I.School Currently Attending or Most Recently Attended
Name
[TM62]
Address (Street, City, State, Zip Code)
[TM63]
J.Physical Characteristics - Child
Describe; e.g., scars, tattoos, birthmarks, discolorations, etc.
[TM64]
K.Behavioral Issues - Child
Describe; e.g., fire setting, physically abusive, sexually abusive, etc.
[TM65]
L. / a. Medical or Mental Health Diagnoses
[TM66] Yes / [TM67] No / Child has been diagnosed with a medical / developmental or mental health problem.
If "Yes", specify.

[TM68]

b. Non-Medical or Mental Health Diagnoses
[TM69] Yes / [TM70] No / Child is believed to have a medical / developmental or mental health problem. If "Yes", specify.

[TM71]

M.Medications
[TM72] Yes / [TM73] No / Child is currently taking medication(s). If "Yes", specify.
1. / Name of Medication
[TM74] / Dosage / Frequency
[TM75]
Reason for Medication
[TM76] / Prescribing Physician
[TM77]
[TM78] Yes / [TM79] No / Have you provided this medication to the care provider? If "No", explain.
[TM80]
2. / Name of Medication
[TM81] / Dosage / Frequency
[TM82]
Reason for Medication
[TM83] / Prescribing Physician
[TM84]
[TM85] Yes / [TM86] No / Have you provided this medication to the care provider? If "No", explain.
[TM87]
3. / Name of Medication
[TM88] / Dosage / Frequency
[TM89]
Reason for Medication
[TM90] / Prescribing Physician
[TM91]
[TM92] Yes / [TM93] No / Have you provided this medication to the care provider? If "No", explain.
[TM94]
4. / Name of Medication
[TM95] / Dosage / Frequency
[TM96]
Reason for Medication
[TM97] / Prescribing Physician
[TM98]
[TM99] Yes / [TM100] No / Have you provided this medication to the care provider? If "No", explain.
[TM101]
N.Special Medical Equipment Needs - Child
[TM102] Yes / [TM103] No / Child has special medical equipment needs; e.g., feeding tubes, respirator, wheelchair, prosthetics.
If "Yes", specify.

[TM104]

O.Allergy(s) - Child
[TM105] Yes / [TM106] No / Child has allergies. If "Yes", check all applicable allergies.
[TM107] Animals / [TM108] Insect bites / [TM109] Stings / [TM110] Soap
[TM111] Food / [TM112] Drugs / [TM113] Dairy products / [TM114] Wool
[TM115] Other - Specify: / [TM116]
Allergy(s) Details; e.g., if you checked "Animals", is the allergy to all animals, or a specific type? Specify type.

[TM117]

Noticeable Allergy Reactions - Describe.

[TM118]

P.Formula and Feeding Restrictions
[TM119] Yes / [TM120] No / Child is currently fed with formula. If "Yes", specify brand and type.

[TM121]

[TM122] Yes / [TM123] No / The child has feeding restrictions; e.g., solids, cups or bottles, swallowing problems.
If "Yes", specify.

[TM124]

Q.Therapeutic Exercises / Activity Restrictions
[TM125] Yes / [TM126] No / Child is required to participate in any therapeutic exercises. If "Yes", specify nature of those exercises.

[TM127]

[TM128] Yes / [TM129] No / Child is restricted from certain activities; e.g., strenuous exercise, climbing stairs, etc. If "Yes", specify activity(s).

[TM130]

R.Medical or Mental Health Appointments
[TM131] Yes / [TM132] No / Does the child have any currently scheduled medical or mental health appointments?
If "Yes", specify.
Date (mm/dd/yyyy) / Time / Name - Provider
[TM133] / [TM134] / [TM135]
[TM136] / [TM137] / [TM138]
[TM139] / [TM140] / [TM141]
[TM142] / [TM143] / [TM144]
II. / SIGNATURES
SIGNATURE - Placing Social Worker / Date Signed
SIGNATURE - Foster Parent / Date Signed
SIGNATURE - Foster Parent / Date Signed

[TM1]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the child’s Person Management page.

[TM2]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM3]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM4]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the child’s Person Management page.

[TM5]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM6]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the child’s Person Management page.

[TM7]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM8]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM9]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the child’s Person Management page.

[TM10]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM11]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM12]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the child’s Person Management page.

[TM13]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the child’s mother's Person Management page. The child's mother is identified on the Parent Info tab of the child's Person Management page.

[TM14]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM15]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM16]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM17]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Address tab of the child’s mother's Person Management page.

[TM18]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Address tab of the child’s mother's Person Management page.

[TM19]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Address tab of the child’s mother's Person Management page.

[TM20]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Address tab of the child’s mother's Person Management page.

[TM21]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the child’s father's Person Management page. The child's father is identified on the Parent Info tab of the child's Person Management page.

[TM22]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM23]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM24]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM25]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Address tab of the child’s father's Person Management page.

[TM26]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Address tab of the child’s father's Person Management page.

[TM27]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Address tab of the child’s father's Person Management page.

[TM28]This field is pre-filled. This field is not editable on the template. The data can be corrected as follows: update the Address tab of the child’s father's Person Management page.

[TM29]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM30]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM31]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM32]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM33]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM34]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM35]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM36]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM37]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM38]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM39]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM40]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM41]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM42]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM43]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM44]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM45]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM46]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM47]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM48]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM49]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM50]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM51]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM52]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM53]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM54]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM55]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM56]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM57]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM58]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM59]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM60]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM61]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM62]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM63]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM64]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM65]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM66]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM67]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM68]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM69]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM70]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM71]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM72]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM73]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM74]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM75]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM76]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM77]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM78]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM79]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM80]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM81]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM82]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM83]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM84]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM85]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM86]This field is user selected. This field is editable on the template. The data can be corrected on the template.

[TM87]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM88]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM89]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM90]This field is user entered. This field is editable on the template. The data can be corrected on the template.

[TM91]This field is user entered. This field is editable on the template. The data can be corrected on the template.