DPP-20 Commonwealth of Kentucky
(R. 2/08) Cabinet for Health and 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 Child Placement Disruption to Higher Level of Care Critical Need
HAS FAMILY HAD AN FTM? YES NO IF 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: http://chfs.ky.gov/
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CURRENT CHILD MALTREATMENT SAFETY/RISK (Check All That Apply):
Physical Abuse Neglect Status Sexual Abuse Dependency N/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 NO IF 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? YES NO IF NO, WHY?
RELATIVE PLACEMENT CONSIDERATIONS (Paternal and Maternal):
Relative's Name / Relationship / Address / Paternal / Maternal1.
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 / TITLE1. / 4.
2. / 5.
3. / 6.
UPON REVIEW OF THIS REFERRAL/CONSULTATION, THE CONSENSUS OF THIS COMMITTEE IS THAT THE ABOVE NAMED CHILD(REN):
Should Should Not Be Placed In OOHC
Should Should Not Be 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)
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