Form Dcfs 561(C) - Psychological/other Examination - Los Angeles Dcfs printable pdf download

COUNTY OF LOS ANGELES • DEPARTMENT OF CHILDREN AND FAMILY SERVICES

DCFS 561(c)

PSYCHOLOGICAL/OTHER EXAMINATION FORM - INSTRUCTIONS

MEDICAL RECORD PROCEDURES FOR FOSTER CAREGIVERS

(Caregiver is a Foster Parent, Relative, Group Home, or FFA).

The HEALTH & EDUCATION PASSPORT (HEP) BINDER accompanies each child at the time of placement. The Children’s Social Worker

(CSW) will review the HEP BINDER with you at each visit.

The Health and Education Passport must be taken to all medical visits, including the initial examination visit. The health care provider must

record all current medical services and tests on the DCFS 561(c). Please add the completed forms to the child’s HEP BINDER.

Immediately notify the child’s CSW (or Supervising CSW, if the CSW is unavailable) when there is any change in the child’s mental,

medical and/or dental health that required urgent medical care.

If the child is removed from your care, the child’s complete HEP BINDER, including the Immunization Record, shall be returned to the

CSW at the time of removal, as the HEP BINDER must accompany the child upon replacement.

(To be completed by CSW/Caregiver. Please print legibly.)

CHILD’s NAME: ___________________________ DOB: __________ CASE #: ______________ DATE PLACED: __________

CAREGIVER: ___________________ (Phone) _______________ (FFA) ___________________ (Phone) _______________

CSW: __________________________ (File #) __________ (Phone) ____________________ (Fax) ____________________

Data entered into CWS/CMS by: (Name) __________________________________ (Date) _________________

__________________________________________________________________________________________________________________

PSYCHOLOGICAL/OTHER EXAMINATION FORM

(To be completed by Mental Health or other Professional Health Care Provider, e.g., Psychiatrist, Psychologist, L.C.S.W., L.M.F.T., Speech

Therapist, Physical Therapist, etc.)

OTHER HEALTH CARE PROVIDER

Date Child Seen: _____________________ Name of Health Care Provider: _________________________________________

Diagnosis/Treatment:

(Treatment given. Medications Prescribed. Please attach copies of supporting documentation; test results, etc.)

(May be continued on additional pages if necessary. If so, provider to also sign and date additional pages.)

________________________________________________________________

Court authorization obtained for psychotropic medication(s)?

Yes Date of Authorization ________________

N/A

(Psychotropic medications for Court dependent children must be authorized by the Court. The Court authorization must be renewed every six months. )

If Yes, what psychotropic medication(s) prescribed? _________________________________________________________

If follow-up care indicated, specify: __________________________________________________________________________

Signature of Health Care Provider: _________________________(Date)__________

Address: _______________________________________ Phone: _______________

(Signature Stamp Required)

DCFS 561(c) (Rev 07/02)

Distribution:

Pages 1, 2 and 3 to foster caregiver when child initially placed.

Page 4 to be filed in Psychological/Medical/Dental folder (purple).

DCFS 561(c) PSYCHOLOGICAL/OTHER EXAMINATION FORM

When page 1 returned, file in Psychological/Medical/Dental folder.

Form Dcfs 561(C) - Psychological/other Examination - Los Angeles Dcfs