CHILD DETAIL (ONE FOR EACH CHILD)
Total Pages ______ /
CHILD DEMOGRAPHICS
Child’s Name:
/ Race:
/ Sex:
MF / Does child have children? If so where at they located.
No Yes
Medicaid #:
/ TANF:
/ SSI:
/ SSA:
/ Other financial information(specify):
Current School:
/ Grade Level:
/ Other educational information (ESE):
MEDICAL / MENTAL / HEALTH INFORMATION
Federal regulations require the child’s health and education record be provided and be updated at the time of each placement. To meet this requirement, the Child Protective Investigator (CPI) must complete the following information or explain why information is not provided.
Does Child have an Alert?
No Yes If Yes provide Alert Code: - - - - A - Alleged Juvenile Sexual OffenderB1 - Sexually AggressiveB2 - Sexually Reactive w/o AggressionC - Physically AssaultiveD - Victim of Sexual AbuseE - Arson / Does Child exhibit an Alert?
No Yes If Yes provide Alert Code: - - - - A - Alleged Juvenile Sexual OffenderB1 - Sexually AggressiveB2 - Sexually Reactive w/o AggressionC - Physically AssaultiveD - Victim of Sexual AbuseE - Arson
Child’s Current Health Provider:
/ Address:
/ Most Recent Visit and Reason:
Has your child ever been in a hospital?
No Yes / If Yes, Name of Hospital:
/ Date: Hospitalized:
/ Reason for Hospitalization:
Do you have any medical records?
No Yes (If Yes attach to this form) / Child Immunization records?
No Yes (If Yes attach to this form) / Child’s known medical problems and current illnesses:
If child’s records are unavailable / inaccessible, please explain why indicating where the records can be located:
Substance Exposed Infant?
No Yes If Yes, Explain: / Blood Disorder:
No Yes Exposed in Utero / Child’s known allergies (food, medicine, dust, animals, etc.):
The child’s special diet or name of formula:
/ Glasses, Prosthetics, Medical and/or special equipment:
Other relevant health information:
CHECK ALL THAT APPLY
Drug Use/Abuse
Alcohol Use/Abuse
Arrests/Criminal Charges
Property Destruction
Stealing
Bedwetting
Soiling / Victim of Violence
Temper Outbursts
Self-Injuring Behavior
Lying
Difficulties in School
Truancy
Suspension from school/work / Developmental Delay
Developmental Disability
Special Education Placement
Treatment of Mental illness
Running Away
Suicidal Tendency
Eating Disorder / Sleep Disturbance
Verbal Aggression
Mood Swings
Frequent Physical Complaints
Frequent Crying
Withdrawn Behavior
Animal Maltreatment
Child Currently in TX/Therapy?
No Yes / Has Child Completed Therapy?
No Yes / Psychological/Psychiatric Diagnosis:
Name of Therapist:
/ Agency:
/ Phone Number:
Name of Mental Health Case Manager:
/ Phone Number:
VICTIM OF SEXUAL ABUSE OR KNOWN SEXUAL OFFENDER
If the child has been a known victim of sexual abuse or has been a known sexual offender, describe when , where, how often and the specific circumstances involved:
If the Child has acted out sexually, engaged in inappropriate sex play for age and maturity or demonstrated a premature understanding of sex, describe circumstance:
Additional information regarding a pertinent behavior or condition listed above which affects the child or parent:
When one or more of these behaviors/conditions are present, they require special consideration for case planning and placement (if applicable). For example, in case child needs out-of-home placement, the plan must specify the child’s daily supervision needed and how the caretaker will assure safety and protection of the victim/offender as well as any other child(ren) in the home.
Based on these behaviors/conditions, the special case planning considerations are: (Copy included in CRR at time of placement? No Yes )
If this is a subsequent placement for the child, what information concerning prior placement history is significant in selecting a new placement?
SAFEPLACE STAFF USE ONLY
Name of Caregiver/Provider:
/ Date of Placement:
/ Type of Placement:
/ Phone:
Address:
Broward Sheriff’s Office Child Profile Placement Referral –CPIS Form # 176 Supervisor Initial: ______
May 2013