Pre-Placement Questionnaire - California Department Of Social Services
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
PRE-PLACEMENT QUESTIONNAIRE
INSTRUCTIONS: If the caregiver does not receive the Health and Education Passport for a “child” and the written plan
identifying the specific needs and services of the “child” at the time of placement, the caregiver shall ask
the placement social worker, at a minimum, all of the following Pre-Placement Questionnaire questions
[Section 89468, Admission Procedures, subsections (b)(1) through (10)] .
CAREGIVER NAME
DATE
CHILD’S NAME
1.
Does the “child” have any allergies? (i.e. any medications, peanuts, strawberries, dogs, cats, etc.)
2.
Does the “child” have a history of infections or contagious diseases?
3.
Is the “child” taking any prescription medications?
4.
Does the “child” have physical limitations? Is any special care needed?
5.
Does the “child” have any medical conditions I should know about? (i.e. diabetes, epilepsy, etc.)
6.
Does the “child” have any mental health conditions I should know about? (i.e. schizophrenia, bi-polar disorder, etc.)
7.
Does the “child” have a history of suicide attempts?
8.
Does the “child” have any behavioral problems? (i.e. drug abuse, running away, or starting fires, etc.)
9.
Does the “child” have a history of physical or sexual abuse?
10. Does the “child” act out sexually?
LIC 9225 (4/10)
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