DCBS Number: / DCBS-84
DCBS Name: / (Rev.1/03)

COMMONWEALTH OF KENTUCKY

CABINET FOR HEALTH AND FAMILY SERVICES

DEPARTMENT FOR COMMUNITY BASED SERVICES

CHILD’S PROFILE FOR ADOPTION MATCHING

NAME:
Child’s Name / Date Created
Date of Birth / Age:
CASE MANAGER: / Phone #:
COUNTY: / Case #:

Note to the worker:This form is used to identify a potential home for the child(ren).

Please feel free to add any pertinent comments that would assist in placing the child.

Siblings
Child is a member of a sibling group / Yes / No
Does this child need to maintain contact with siblings? / Yes / No
Number of siblings to be placed together
Names of siblings to be placed together
First Name / Last Name / DOB

Please identify the condition(s) that a child has and the severity of that condition. This form is used to identify a potential home for the child. Feel free to add any pertinent comments that would assist in placing the child.

Scale:

0=Child does not have this need/condition.

1= Child’s need/condition is mild.

2=Child’s need/condition is moderate.
3=Child’s need/condition is severe.

  1. Emotional
Health/Behaviors. / 0 / 1 / 2 / 3 / Comments
1.Attachment History
2.Mental Health Intervention
Yes / No
3.Substance abused
a.Tobacco User
b.Drugs/Alcohol
4.Sexually Abused
5.Physically Abused/Neglected
6.Ritualistically Abused
7.Destructive tendencies / 0 / 1 / 2 / 3 /

Comments

a.Animals
b.Property of Others
c.Child’s Possessions
8.Aggression towards others. / 0 / 1 / 2 / 3 /

Comments

a.Physical
b.Verbal
9.Eating Disorder
10.Sexual acting-out issues. / 0 / 1 / 2 / 3 /

Comments

a.sexually active
b.sexual behaviors
c.sexual identity issues
d.history of sexual perpetration
11.Bed Wetting

Please identify the condition(s) that a child has and the severity of that condition. This form is used to identify a potential home for the child. Feel free to add any pertinent comments that would assist in placing the child.

Scale:

0=Child does not have this need/condition.

1= Child’s need/condition is mild.

2=Child’s need/condition is moderate.
3=Child’s need/condition is severe.

  1. Education Performance
/ 0 / 1 / 2 / 3 / Comments
1.Mental Retardation
2.ADHD
3.Specific Learning Disability
4.Classroom Setting
5.Disruptive in classroom
6.Aggressive in classroom
7.Oppositional Defiant in classroom
8.Truancy
  1. Physical Health
/ 0 / 1 / 2 / 3 / Comments
1.Hearing Impairment
2.Vision Impairment
3.Speech Impairment
4.Chronic medical condition that requires on-going medication and treatment
Yes / No
5.Controlled Physical Environment (i.e., Non Smoking environment)
6.Medical condition that can be corrected
7.Medical condition that may require surgery at a later date
8.Chronic life threatening medical condition
9.Terminal illness
  1. Self-Care (Age Appropriate)
/ 0 / 1 / 2 / 3 / Comments
1.Needs assistance with Feeding
2.Needs assistance with Bathing
3.Needs assistance with Dressing
4.Needs assistance with Grooming
5.Needs assistance with Hygiene

Please identify the condition(s) that a child has and the severity of that condition. This form is used to identify a potential home for the child. Feel free to add any pertinent comments that would assist in placing the child.

Scale:

0=Child does not have this need/condition.

1= Child’s need/condition is mild.

2=Child’s need/condition is moderate.
3=Child’s need/condition is severe.

  1. Mobility
/ Yes / No / Comments
1.Wheelchair
2.Walker/Braces/Crutches
3.Deformed or Missing Limbs/Prosthetic devices
4.Partial Paralysis
5.Total Paralysis
  1. Family History
/ Yes / No / Comments
1.Mental illness
2.Substance Abuse
3.Mental Retardation
4.Domestic Violence
  1. Legal Risk
/ Yes / No / Comments
1.
2.
Completed by : / Date completed :

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