Children’s Review Program Foster Care Six Month Progress Report

If the PCC fails to submit the CRP-003 by the due date, payment shall be terminated. The PCC may file a request for a fair hearing using the DSS-154, Request for Fair Hearing, within thirty (30) days of termination of payment.

Beginning Date	Ending Date	Type of Foster Care	County of Foster Home
Month	Day	Year	Month	Day	Year	DCBS PCC
Basic Therapeutic Medically Fragile
Name of PCC Agency	Case Manager	Telephone	Fax
County of DCBS Worker	Name of DCBS Worker	Telephone	Fax
Is the State Worker (listed above as Case Manager) different from the one listed on the last Quarterly Report?	Yes No
CHILD INFORMATION

Child’s Name (Last, First, M.I.)	Social Security #	Sex	Race	Date of Birth	Admission Date to Current Placement
M F
ATTACHMENTS

This report is designed to allow the author to attach and reference professional documentation to avoid duplication of effort. Please include the most recent PCC Treatment Plan and/or the Child Information Sheet and Action Plan from the DCBS Case Plan. Check below the attached documentation and cross-reference within this report by citing the page, section or item number. Incomplete reports will be returned.

Treatment Plan	DCBS Case Plan	Medicaid Monthly Progress Report	Medicaid Plan of Care Approval Form

Medically Fragile Monthly Report	Psychiatric	Psychological	Psychoeducational Evaluation	Other

PROGRESS TOWARD GOALS

Please indicate progress toward goals and any changes in the treatment/case plan that has occurred in the last 6 months.

SEE ATTACHED (Give information, location referenced by page and section)

In the last 6 months, has there been a change of residence, service or supervision? YES NO

If YES, please explain reason and date of change.

PARENT/GUARDIAN INFORMATION

If the plan is to return the child to an adult’s care (e.g., parent, relative, adoptive parent, etc.), please provide the following information about that person(s). If not applicable due to TPR, etc check the “N/A” box and continue to section E.

N/A SEE ATTACHED (Give information, location referenced by page and section)

Last Name	First Name	Relation To Child	Phone
Mailing Address	City	State	Zip Code

Please indicate how the PCC and/or foster parent are involved with the child’s family. Please describe the services/treatment interventions the child’s family receives. If no services check the “NO SERVICES” box and indicate the reason.

NO SERVICES

PERMANENCY GOAL

Projected Date of Discharge:	_____________ Briefly state any change in Permanency Goal in the last 6 months.

Month / Year

SEE ATTACHED (Give information, location referenced by page and section)

If this is a DCBS foster home, has the child's DCBS worker visited the child at least once per month for the last six months at the foster home? YES NO

If this is a PCC foster home, has the child's DCBS worker visited the child at least once every three months for the last six months at the foster home? YES NO

BEHAVIORAL INCIDENTS

Please indicate below any severe behavioral incidents that have occurred in the 6 last months where the child has been a danger to self, others, property or a severe disruption to the home, school or community. Please note if legal charges were filed as a result of the incident. Note any additional incidents in the space marked ”Other.” If there are no incidents, please check the “NO INCIDENTS” box.

NO INCIDENTS	SEE ATTACHED (Give information, location referenced by page and section)

Behaviors	Brief Description and # of the behavior(s) in this past 6 month period
Physically Aggressive Acts

Verbally Aggressive Acts

Bizarre Behaviors

Destroying Property

Homicidal Behavior

Impulsivity - Dangerous

Substance Use

Runaway

Self-Abusive/Self-Mutilating Behavior
Sexualized Behaviors

Suicidal Behavior (Specify attempt, threat, etc.)
Other:

Are any of the above behaviors getting worse or more frequent? YES NO If YES, explain.

METHODS OF BEHAVIOR MANAGEMENT

Method	Frequency	Has the use of these methods become more frequent? Explain.
Use of Time-out

Physical Management/

Restraint
Calling outside assistance

Other:

SOCIAL SKILLS

Briefly describe child’s social interactions with peers and adults. Include descriptions of the need for supervision in public; assistance with hygiene issues and daily living skills; and employment/extracurricular activities within the past 6 months. Note specific behaviors and staff response to such behavior. (This section must include progress toward MEDICAID REHABILITATIVE SERVICES living skills development goals if applicable.) SEE ATTACHED (Give information, location referenced by page and section)

Based on the child’s age, is his/her need for supervision age appropriate? YES NO If NO, explain.

EDUCATION/CHILD DEVELOPMENT

Please complete the following information. SEE ATTACHED (Give information, location referenced by page and section)

School Services:

Regular Education

Special Education

(Please describe, e.g. EBD, LD, etc)

Day Treatment

GED

Vocational

College

Partial Hospitalization

Home Bound	Not in School

Pre School

First Steps

Head start

Kindergarten

Other	Current Grade Level:

Please summarize any academic progress or lack of progress in academics during the last 6 months. SEE ATTACHED (Give information, location referenced by page and section)

Has caregiver had to intervene in the school setting with this child in the last 6 months? YES NO

If YES, approximate number of interventions: ________

Please briefly explain reasons for interventions and frequency of interventions. Use an additional sheet if necessary. SEE ATTACHED (Give information, location referenced by page and section)

Is the child able to ride the school bus? YES NO If NO, explain.

MEDICAL

Has the child had any major illnesses, medical complications, or medical hospitalizations in the last 6 months? YES NO

If YES, please explain and indicate medical diagnoses, frequency of medical treatment and the extent to which caregiver time and resources were utilized (attach additional sheets if necessary).

SEE ATTACHED (Give information, location referenced by page and section)

Does the child have any chronic illnesses, diagnoses or disabilities? YES NO

If YES, please explain and indicate the medical diagnoses and the extent to which caregiver time and resources were utilized (attach additional sheets if necessary): Include medical incidents. For medically fragile children, attach ACUTE MEDICALLY FRAGILE/MEDICALLY FRAGILE - MONTHLY REPORT(S) for this reporting period.

SEE ATTACHED (Give information, location referenced by page and section)

MEDICATIONS

List child’s current medications, purpose, and date prescribed.

SEE ATTACHED (Give information, location referenced by page and section)

#	Medication with Dosage	Purpose	#	Medication with Dosage	Purpose
1
4
2
5
3
6

MENTAL HEALTH THERAPY/ SUBSTANCE ABUSE TREATMENT/OTHER THERAPY

Is the child currently receiving mental health or psychiatric services? YES NO

If YES, please complete the following, applicable information. (Include progress toward Medicaid Rehabilitation Services counseling, therapy, consultation, assessment, goals, etc., if applicable.)

SEE ATTACHED (Give information, location referenced by page and section)

Type of Services Offered to Type of Treatment	Total Number of Sessions Received the last 6 months	Name of Agency/Program Providing Service	Provider Name(s)

(Psychiatrist, therapist, etc.) including degree/specialty
Individual Counseling
Group Counseling
Psychiatric Interventions
Family Counseling
Substance Abuse Counseling
Occupational Therapy
Physical Therapy
Speech Therapy
Other Interventions:

Current DSM-IV diagnosis (Axis I & II only). SEE ATTACHED (Give information, location referenced by page and section)

Axis I: ______________________________________________________________________________________________________

Axis II: _____________________________________________________________________________________________________

Please specify reason for any change in DSM-IV diagnosis.

OTHER

Please indicate any other significant information regarding this child and his/her progress in the last 6 months. This can include any special programming needs or any other information that has not been addressed previously in this report (attach additional sheets if necessary).

SEE ATTACHED (Give information, location referenced by page and section)

SIGNATURE OF REPRESENTATIVE

____________________________________________	______________

Signature of DCBS Case Manager/PCC Representative	Date

BE SURE YOU HAVE ATTACHED AND REFERENCED ANY SUPPORTING DOCUMENTATION!

Distribution:

Children’s Review Program

Social Services Worker

Resident’s Facility File (if applicable)

3

4

CRP-003

(Rev.3/02)

922 KAR 1:360

PRIVATE CHILD CARE MONTHLY PROGRESS REPORT

Tye Reece

2002-03-07

BJ.Jacobs