Date: ______

CHILDREN AND FAMILY SERVICES

CHILD’S NEEDS AND SERVICES PLAN FOR AGES BIRTH TO 19

*** CNSP must be completed/ updated at least once every 6 months and with each placement change

CNSP Information

Initial Modification Needs/Plan Semi-Annual Review/Evaluation
Other ______

Child Information

Name: ______
Age: ____ Date of Birth: ______Sex: ____
Ethnicity: ______
Primary Language:______Religious Preference: ______
Medi-Cal # ______
City of Origin: ______

Minor Parent: Yes No If Yes:

Child placed with dependent parent: Yes No
If no, child’s placement: ______
Is child a dependent: Yes No
Childs name:______DOB: ______
Special Needs of child:
Additional Information:

Placement Information

Initial
Name of Caregiver:______
Date of Placement: ______
FTM and Transition Plan ______
______
Placement Disruption Notice (7- days or Other) Date Given______
Planned Placement Change Anticipated Date:______
Reason for Placement Change: ______
Name of New Caregiver: ______
FTM and Transition Plan ______
______
______
Reason for Detention (check all that apply)
General NeglectSevere Neglect Physical Abuse
Sexual AbuseEmotional Abuse
Type of New Placement:
RelativeSmall Family HomeFFAGroup Home
Foster HomeSTRTPTri-Counties Regional Center
Emergency Shelter Foster Home (30-60 days max)
Is this child part of a sibling group to be placed together : Yes No
Number of Siblings _____
Reason for not seeking to place the siblings together:
______

Placement History (types and number)

This is the child’s first placement Probation(#)
Relative Care(#) Foster Care(#)
Residential/Group Home (#) Shelter Care(#)

Child’s Attorney Information

Child’s Attorney: ______Phone #: ______

E-Mail: ______

Visitation (Foster Care Standard Practice: weekly visits)

Mother______Father______Other ______
Supervised
Monitored
Unsupervised
Supervised/Monitored by Whom: ______
Frequency:______
Not Applicable Reasons:______
Visitation with Siblings: Yes No Plan: ______
______

Child Successes/ Positive Behaviors Observed

Behavior Alerts/Risks:

Current and Historical Child Behavior Alerts:
Assaultive Fire Setting Sexual Acting Out Severely Withdrawn
Suicidal Hx of Suicide Attempt(s) Drug Use Other ______
None of the Above Unknown
History of: Physical Abuse Sexual Abuse
Comments (required when box is checked):

Abilities of Child (i.e. physical limitations, Regional Center objectives, ILP activities):

Interests and Extracurricular Activities of the child:

Health and Education Information

Lifebook provided and discussed:YesNo
Plan for recording and sharing child milestones/ updates with parents:
______
______
FOSTER HEALTH LINK DISCUSSED: Yes

Education

Child is not school age
Child previously had an IEPChild currently has an IEP
Child is enrolled in school and will remain in school of origin and requires transportation by caregiver
Child needs to be enrolled in school
Name of CurrentSchool:______Grade: ______

Mental Health/Social Emotional

None Unknown
Confirmed Diagnosis within last year:______
Date of diagnosis and by whom: ______
Current Medication:______
Court Authorization for medications in place (JV220): Yes No Needed
Prescriptions Needed:
Clinicians Name and contact information:
Date of Next Appointment:
Developmental Delays:
Displayed behaviors (observable and specific):

Medical and Dental

Medical Conditions:
Unknown
None
Current Medications taken:
Prescriptions needed:
Allergies:
Medical and dental conditions:
Special Diet:
Physician name and contact information:
Dentist name and contact information:
Next Scheduled appointment:
Date of last medical exam:
Date of last dental exam:
Exposure to Infections/Contagious Disease(s) within last year: Yes No
If Exposed, provide details: ______
IHCP Yes No Needed
Next Steps: ______

Newborn Special Information

Formula Type: Milk-based Soy-based Breast Fed? No Yes
Feeding Problems? No Yes, the infant needs:______
Born Drug Exposed? No Yes Unknown
Drugs exposed to: ______Unknown
Medically Fragile? No Yes, the infant needs:______

To Be Completed by Caregiver at Time of Placement

  1. I have received and understand thefoster/shelter/relative/group home care Placement Agreement form (California Department of Social Services Manual of Policy and Procedures section 31-075).
  1. I have received the County of Ventura Children & Family Services 24 hour hotline phone number: (805) 654-3200 (CDSS MPP sec. 31-405).
  1. I have been informed of any dangerous propensities and/or behavioral problemsof the child per the foster/shelter/relative/group home care placement agreement (CDSS MPP sec. 31-075, 31-310 & 31-405).
  1. I understand that any facts regarding the child’s known or suspected dangerous behavior(s) are confidential and that unauthorized disclosure could result in a $1,000 fine (CDSS MPP sec 31-310 and 31-405).
  1. I have received, read and signed the Notice to Foster Caregiver Regarding CHDP Medical and Dental Examination Requirements (form 56-12-80). I understand that the initial examinations must be completed within 30 days of the child’s placement in my home unless completed previously (CDSS MPP sec 31-075 & 31-405).
  1. The social worker has discussed with me the child’s health history as known and any suspected medical problems. I understand the social worker is to provide the child’s immunization records or make arrangements for provision of the immunization records (CDSS MPP sec 31-405).
  1. I have received a copy of the child’s Lifebook and discussed plans for recording and updating milestones/ updates with birth parents(CDSS MPP sec 31-405).
  1. I have been informed of the child’s family’s background (CDSS MPP sec 31-405).
  1. I have been informed of the type and number of the child’s previous placements and the reason for change in placement (CDSS MPP sec 31-405).
  1. I have been informed of the child’s grade, educational status and current school, as age appropriate (CDSS MPP sec 31-405).
  1. The child will remain in their school of origin. I understand that the child will not change schools without prior consent from the social worker.
  1. I understand that youth 16 years and older will receive transitional independent living services as described in a Transitional Independent Living Plan (TILP) developed between the youth and the social worker. My input and assistance may be needed to help develop the plan.
  1. I have received and will complete the child’s Client/Resident Personal Property and Valuables list (LIC 621) at time of placement and when child changes placement, returns home, or emancipates.
  1. I acknowledge that it is the expectation that I assist with transporting the child to visits with family members, including siblings in other placements.
  1. I have been informed of the expectation to provide travel arrangements for the child to their school of origin and may receive reimbursement for providing such transportation if such transportation meets the Educational Travel Reimbursement criteria reimbursement.

16. I will participate in Family Team Meetings regarding the child. Childcare may be requested by caregivers for children in their home to support their involvement in Family Team Meetings.

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CHILD’S NEEDS AND SERVICES PLAN

Name of Child:______

Check One Regarding Receipt of Court Order:

I have been given a copy of the Court order authorizing me to secure routine medical or dental care for the minor; and permitting the child to travel with me throughout the United States, provided there is prior permission from HSA. / I have not received a Court order yet. I understand it is the social worker’s responsibility to give me a copy of the most recent Court order when the Juvenile Court provides that order to the social worker. If I do not receive a copy of the Court Order within 30 days, I will contact the social worker and/or social worker’s supervisor.
CAREGIVER RESPONSIBILITIES TO MEET NEEDS OF CHILD: / DATE NEEDED:
  1. ______
  1. ______
  1. ______
  1. ______
  1. ______
  1. ______
/ ______
______
______
______
______
______

I, the Caregiver, have reviewed, understood, and agreed to support the child’s plan.

Caregiver Name: ______

Caregiver Signature: ______

Date

CWSW Name: ______Phone: ______

E-Mail: ______

CWSW Signature: ______

Date

CWSW Supervisor Name, Phone, Email: ______

Child Signature (As age appropriate): ______

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