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Carpe Diem Internal Transfer Form

(To be completed by the departing Case Manager and Foster Parent prior to pre-placement visits/moving of our children internally)

Name of Child: ______

Date of Birth: ______

Health Card Number: ______

Greenshield/Health Plan Number: ______

Placing Agency: ______

CAS Workers Name: ______Telephone #: ______

Departing Foster Home: ______

Departing Case Manager: ______

Why is the child moving: ______

______

______

Moving to (New Foster Home): ______

New Case Manager: ______

Medications:

Name of Medication(s): / Doctor who prescribed it: / Dosage: / Exact time of medication: / Date/Time of next Review

How much Medication will be accompany the child upon Admission to the new foster home: ______

______

Immunization Records up to Date: Yes_____ No______(If no, what is needed): ______

______

Date of Last Dental:______Dentist Name______

Telephone #______

When does the next appointment need to be arranged for: ______

Date of Last Optical: ______Doctor’s Name:______

Telephone #______

Date of Annual Physical:______Doctor’s Name:______Telephone#______

Is the Child seeing a Paediatrician: Yes_____ No ______

If Yes:

Name of Doctor______Telephone#______

Reason for seeing______

Other Specialist’s involved with the Child: Yes _____ No_____

If yes,

Doctor’s Name ______Telephone #______

Reason for seeing ______

School/Day Care:

Name______Grade______

Address______

Telephone #______

Teacher’s Name/Contact Person______

IEP: Yes ______No ______

If yes, what is modified ______

IPRC: Yes ______No ______

If Yes, what is the designation:______

Is a copy of the IPRC provided to the New Foster Parent to assist with enrolment in the new school: Yes ______No ______

Upcoming Appointment Dates (ie. court, medical, assessment, therapy) and who is to attend:

______

Access Visits (dates, times and location) and state if drives are in place:

______

Clothing

Does the child have appropriate Seasonal Clothing: Yes _____ No _____

If no, what is required______
______

Please include some personal information that will make the child’s transition as easy as possible. Example: food likes and dislikes, comfort items, bedtime routines, wake up and normal bedtimes at current home, particular triggers for anxiety, fears, need for night lights, sleep disruption, night time wetting or wandering, difficulties with transitions. How child is prior to or after access visits, Nicknames etc.

______

Attached last POC if possible: Yes ______No ______

Date of Pre-placement visits, if possible: ______

Next relief date, if known: ______

Date of transfer: ______

Signatures: ______

9355 Dixie Road, Brampton, ON L6S 1J7 Tel: 905.799.2947 Fax: 905.790.8262 Email: