Youth:
Date of Birth: / PATH Case Manager:
Resource Home:
Month/Year: / Date:
PHYSICAL HEALTH - MEDICAL/DENTAL/VISION
Youth’s general health this monthMedical appointment dates:
Reason for appointment(s):
Outcome of appointment(s):
Annual physical exam
Approximate date of next medical/physical exam:
Dental appointment dates:
Outcome of appointment(s):
Approximate date of next semi-annual cleaning/exam:
Vision appointment dates:
Reason for appointment:
Outcome of appointment(s):
Approximate date of next vision exam:
Physical Health Medications: List on-going physical health medications (dose and frequency):
List dosage changes:
List new medications:
Comments: / Excellent / Good / Fair / Poor
MEDICATIONS (Psychiatric)
Psychiatric Medication Management appointment date(s) and provider:
List on-going medications (dose and frequency):
List dosage changes:
List new medications:
Comments:
EMOTIONAL and behavioral HEALTH
Youth attends counseling?Is the counseling meeting the needs of the youth?
Number of sessions attended this month:
Additional Emotional/Behavioral Services:
Comments: / YES
/ NO
Behaviors seen this month
Physically Aggressive toward peersPhysically Aggressive toward adults
Oppositional/ Breaks Rules
Threatens others
Is cruel or bullies others
Talks about killing self Attempt Threat
Talks about killing others Attempt Threat
Does not feel guilty for misbehavior
Blames others
Substance use
Steals
Demands attention
Can’t sit still, hyperactive
Difficulty concentrating
Worries excessively
Sad or unhappy after communication
with biological family
Impulsive, not dangerous
Impulsive/dangerous
Wets self during day Wets bed / Stares blankly
Sulks, pouts, whines
Acts fearful
Sleep problems
Lacks energy
Lies or cheats
Self harm
Cries more than usual for their age
Screams
Eating problems
Lies, deceitful
Swears, Uses profanity
Temper tantrums
Withdraws or isolates self
Has sudden mood swings
Refuses medication
Expresses feelings of worthlessness
Left without permission
Ran away
Hurts animals
Has bowel movements outside the toilet
Does not get along with other youth
Sexually acts out Explain:
Exhibits strange behavior: Explain:
Hallucinations, Type:
Destroyed property Explain:
Are any of the behaviors getting worse or more frequent? Yes No
If yes, explain:
Please list any other behavioral concerns:
Comments:
·
Safety/Critical Incidents
NO INCIDENTS SAFETY/CRITICAL INCIDENTS (List below)Safety holds or restraints Medication Errors Property Damage Self-harm behavior
Serious illness or injury that requires hospitalizations or emergency room visit
Absent from the foster home without permission Allegations
Law violations that result in foster youth’s detainment, arrest, or other involvement with law enforcement.
Other (see critical incident categories)
Comments:
METHODS OF BEHAVIOR MANAGEMENT
Method / Frequency / Has the use of these methods become more frequent? Explain.
Use of Time-out
Youth Safety Hold
Calling outside assistance from PATH worker
Use of natural consequences
Other - Explain
Cooperative family living and personal care
Completes chores without reminders or coaxing?Does a chore only with reminders and/or directions?
Participates in family activities (Meals, games, discussions, etc
Practices age appropriate self-care and hygiene routines.
Comments: / YES / NO / SOMETIMES
INDEPENDENT LIVING SKILLS
Money management, employment skills, care of home and possessions, conflict resolution, assertiveness, menu planning, food purchasing and cooking, career planning, transportation, paying bills, housing options, education planning, etc…Has an Independent Living Assessment been completed?
Have you received a copy?
Youth 16 and above had contact with Independent Living Worker?
What IL activities were worked on with the youth in the foster home?
What IL activities took place in the community?
Comments: / YES / NO
YOUTH’S OWN FAMILY CONNECTIONS:
Contact with mother?Contact with father?
Contact with sibling(s)?
Contact with extended family/kin?
Comments: / Contact / If yes, indicate type of contact
YES / NO
/ NA / PHONE / LETTER / VISIT / OTHER
RELATIONSHIPS
Relationship with your family:Relationship with their own family:
Relationship with peers:
Relationship with PATH Case Manager:
Relationship with authority figures:
Able to express feelings and thoughts:
Comments: / Excellent / Good / Fair / Needs work / N/A
Religion/Spiritual development
Does the youth have the opportunity to practice a faith of their choice?Conflicts or issues about religion?
Comments: / YES / NO
educational development
Youth in school?Attitude/behavior with teachers and staff?
Attitude/behavior with peers?
Attitude/behavior toward homework?
Overall effort toward schoolwork?
Attended School Parent /Teacher conference? Copy of report card to PATH Case Manager?
Youth on Individual Educational Plan (IEP)? Attended IEP meeting?
Comments: / YES / NO
/ N/A / EXCELLENT / GOOD / FAIR / NEEDS WORK / NO EFFORT GIVEN
Enrichment activities
What extracurricular, recreational and/or leisure time activities does the youth participate in?Talents and interests youth is working on:
Has the youth started or stopped participating in a sport/hobby/activity/talent?
What opportunities to participate in cultural activities/events are available and does the youth participate in these opportunities?
Comments:
respite
Have you used respite this month?If yes, who provided respite?
Dates of respite:
Was respite pre-arranged?
Do you have a need for respite?
Comments: / YES / NO
legal involvement
Attended court hearing?Date:
Hearing type: Child Protection or Juvenile
Were you given written notification of court hearing?
Comments: / YES / NO
pATH TREATMENT PLAN
Do you see movement toward achieving the treatment plan goals?Do you see movement towards the identified permanency goals?
Did you actively contribute and participate in development of the individual treatment plan?
Did the youth actively contribute and participate in development of the individual treatment plan?
Did you attend the Monthly Team Meeting?
Is the plan current?
Did you receive a copy?
Comments: / YES / NO
Was there contact with the CASA (GAL) worker this review period?
Type of Contact:
Comments:
Did the youth’s legal custodian have contact with the youth this review period?
Type of Contact:
Comments:
Has the PATH worker had contact with you and the youth this month?
List Dates of visits:
Comments:
CLOTHING
Clothing or other items purchased this month:If yes, what was purchased? / YES / NO
FOSTER PARENT NEEDS & PROMPTS
Do you need any additional support or services to maintain this youth in your home?If yes, explain?
Any other concerns, issues or other topics that need discussed?
If yes, explain:
Continued education accessed or requested?
Quarterly Fire Drill performed? Date: / YES / NO
Other comments
Dates of contact between PATH Worker and Case Worker (completed by PATH )Resource Parent Signature: / Date:
PATH Case Manager Signature: / Date:
Visitation Log
To be filled out by Resource Parent: Record all visitors having contact with the child
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Page 2 of 9 Revision 09/29/14