CHILD INFORMATION FORM FOR RESPITE PROVIDER MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION

I. RESPITE INFORMATION:

Child's Name:	Child's DOB:

Child's Medicaid Number/DCN:

Respite dates: to Drop off time: am/pm Pick up time: am/pm

Emergency Numbers: Foster Parent

Social Worker:	Child's Physician ________

II. CHILD’S BACKGROUND:

A. Check all that apply to the child:

Strengths

Helpful	Intelligent	Honest	Enjoys art	Dependable	Articulate
Good hygiene	Enjoys sports	Enjoys music	Interacts well w/others	Respects authority	Well-Mannered
Accepts change	Generous /Shares	Good with younger children	Leadership qualities	Accepts diversity in others	Compassionate

Needs Support

Honesty	Bedwetting	Being Safe	Sharing	Hygiene	Toilet training
Anger Management	Not acting out sexually	Nightmares / Insomnia	Supervision around pets	Keeping things orderly	Tolerating redirection
Accepting responsibility for behavior	Not taking others property	Understanding due to lower IQ	Close supervision by caring adult	Supervision w/younger kids	Mental limitations and abilities

B. Check all that apply to the child:

Suicidal	Physically Aggressive	Verbally Aggressive

Sexually inappropriate	Destruction of Property	Fire-Setting

Crimes-Delinquency	Sexually Active	Substance Abuse

Depression	Elopement	Medication needed

Medical (explanation e.g.: broken arm) ___________________________________

1. List diagnosis: __ ___________________________________________________________

2. List all medications, time, and dosage: ______________________________________________________________________

__________________________________________________________________

III. RESOURCE PARENT CHECKLIST:

(Resource parent, please provide the following to the respite provider)

Placing Foster Parent has notified the child's case manager of respite details,

dates, Respite Provider, and phone number

Medicaid number

Health information, social worker information, child information

Inventory: clothing, special equipment, eye glasses, toiletries e.g. toothbrush

________________________	___________________

Resource Parent's Signature	Date