Legal Name of Child: Age: Date of Birth: Known as: Requested Date of Placement: Wardship Status: Corrections Status: Reason for Placement Request: Name/Address of Placing Agency: Name of Child’s Worker: Phone: Fax Number: E-mail:
Child’s Medical/Health Condition: Excellent Good Fair Poor
Child’s Condition/Diagnosis(es): Child Health Card Number: Drug Plan: Date of Last Medical Examination: RX Name: RX Name: RX Name: RX Name:
Please Note: We request a sufficient supply of all ongoing medication to be sent along with the child to allow for adequate medical follow-up in the area of placement.
Any Known Allergies: Mental Health Diagnoses/Conditions: Requirements for Ongoing Contact/Assessment: Psychiatrist Psychologist Speech/Language Eyes Ears Teeth Physician Other
Child’s Family (please include any relevant information and/or contact information)
Mother: Father: Siblings:
Other important/ caregiving relatives:
Summary of Previous Placements/Resources (please indicate length of placement, as well as whether or not treatment programs were successful or not):
Method of placement:
Summary of child’s history:
Concerns about placement or anticipated behaviours:
Child’s Education Status: Special Education Identification Yes No
Child’s last completed school grade:
Please attach any relevant documents, such as child protection histories/documents, court summaries, educational assessments/reports, psychological and/or social work assessments, etc.
Reports attached:
Physical description of child: Height: Weight: Eye Colour: Hair Colour: Length/ Style: Complexion: Scars: Tattoos: Birth Marks:
Culture/Ethnicity: Practicing: Yes No N/A
Child’s Religion: Practicing: Yes No N/A
Child’s likes and dislikes:
Child’s hobbies/skills/talents, etc:
Any other information you feel would be beneficial for the treatment resource and/or would assist in making the transition smoother for this child?
