DPP-20 Commonwealth of Kentucky

DPP-20 Commonwealth of Kentucky

(R. 2/08) Cabinetfor Healthand Family Services

Department for Community Based Services

Division of Protection and Permanency

UTILIZATION REVIEW CONSULT FORM

DATE OF CONSULTATION:

CASE NAME: CASE #:

SSW: FSOS: COUNTY:

TYPE OF CONSULT:

Removal of ChildPlacement Disruption to Higher Level of CareCritical Need

HAS FAMILY HAD AN FTM? YES NOIF YES, DATE OF LAST FTM:

Child A:
Name: / Child B:
Name: / Child C:
Name: / Child D:
Name:
Gender: / Gender: / Gender: / Gender:
DOB: / DOB: / DOB: / DOB:
SSN: / SSN: / SSN: / SSN:
Mother: Name, DOB & SSN / Mother: Name, DOB & SSN / Mother: Name, DOB & SSN / Mother: Name, DOB & SSN
Father: Name, DOB & SSN / Father: Name, DOB & SSN / Father: Name, DOB & SSN / Father: Name, DOB & SSN

FAMILY HISTORY (Include DCBS Report history, Criminal history, Family Strengths, etc):

PRIOR OOHC PLACEMENTS?YES NO

(If yes, please attach placement log from TWIST)

Cabinet for Health and Family Services An Equal Opportunity Employer M/F/D

Web site:

Page 1 of 3

CURRENT CHILD MALTREATMENT SAFETY/RISK (Check All That Apply):

Physical AbuseNeglect StatusSexual AbuseDependencyN/A

SITUATION INDICATING POSSIBLE OOHC PLACEMENT/DISRUPTION/CRITICAL NEED (Describe Circumstances of need for OOHC Placement, Disruption, or Critical Need):

WAS REMOVAL OF PERPETRATOR CONSIDERED? YES NOIF NO, WHY?

SERVICES CONSIDERED TO PREVENT OOHC PLACEMENT/DISRUPTION/CRITICAL NEED (Document services considered [e.g., FPP, FRS, FPS, counseling/therapy, day care, IMPACT, medications for children, Preventive Assistance, etc.]):

IS AN ABSENT PARENT SEARCH NEEDED? YESNO IF NO, WHY?

RELATIVE PLACEMENT CONSIDERATIONS (Paternal and Maternal):

Relative's Name / Relationship / Address / Paternal / Maternal
1.
2.
3.
4.

CULTURAL AND SPECIAL MEDICAL CONSIDERATIONS (e.g., religious preference, language, developmental disability, physical impairment, diabetes, seizure disorder, etc.):

_

IS CHILD PLACEMENT BEING SOUGHT IN COUNTY OF ORIGIN?YES NO

ARE CHILD’S NEEDS BEST MET BY A DCBS RESOURCE HOME?YES NO

ARE CHILD’S NEEDS BEST MET BY A PCP FOSTER HOME?YES NO

ARE EFFORTS BEING MADE TO PLACE SIBLINGS TOGETHER?YES NO N/A

IF NO, WHY?

URC PARTICIPANTS:

Name / TITLE / NAME / TITLE
1. / 4.
2. / 5.
3. / 6.

UPON REVIEW OF THIS REFERRAL/CONSULTATION, THE CONSENSUS OF THIS COMMITTEE IS THAT THE ABOVE NAMED CHILD(REN):

ShouldShouldNotBe Placed In OOHC

ShouldShould NotBe Moved To A Higher Level Of Care

COMMITTEE CONSENSUS ON CRITICAL NEED/OTHER PLACEMENT DISRUPTION:

COMMITTEE RECOMMENDATIONS:

Signature of MSW (Required)Date

File Original:Regional Gatekeeper

File Copy: Requesting FSOS

DPP-20
(R. 2/08)

Page 1 of 3