Form Soc 837 - Supplement To The Rate Questionnaire

Download a blank fillable Form Soc 837 - Supplement To The Rate Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Soc 837 - Supplement To The Rate Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SUPPLEMENT TO THE RATE QUESTIONNAIRE
NAME OF CHILD/YOUTH:
AGE OF CHILD/YOUTH (SUPPLEMENT FOR CHILDREN THREE (3)
YEARS OF AGE AND OLDER):
DATE FORM COMPLETED:
DATE OF REQUEST FOR SUPPLEMENT:
This form must be completed by the county child welfare services worker or the adoption worker and regional
center coordinator or other regional center representative by telephone, fax, e-mail or mail, followed by a signature
from that individual, and followed by a signature from the individual reviewing the document and returned to the
county or adoptions district office within ten (10) business days for processing. The county may collect
information from other professionals by telephone, fax, e-mail or mail.
For each item 1. (one) through 10. (ten) below, please indicate your response by placing a check mark inside only
one of the three boxes provided. For item 11. below, indicate a YES response by placing a check mark in either box
(a) or box (b) or indicate a NO or DO NOT KNOW response. Any item with a DO NOT KNOW response from the
regional center should be referred to other professionals (marriage and family therapist, licensed clinical social
worker, or other medical, developmental, educational, or mental health professionals) who have relevant
information regarding the condition and needs of the child. Information may be obtained by telephone, fax, e-mail
or mail, followed by a signature by the individual reviewing the document, and returned to the county or adoptions
district office within ten (10) business days for processing.
Complete the questionnaire to the best of your ability. When responding, keep in mind that the deficits must be
beyond what would be expected for the age of the child or youth.
DEFICITS IN SELF-HELP SKILLS
1. The child/youth requires constant care and supervision for basic and essential daily care; the child/youth does not
independently perform such self-care activities (e.g.: dressing, eating, toileting, bowel or bladder control, bathing,
menstrual care and personal care (such as grooming activities) .
■ ■
■ ■
■ ■
YES (If YES, skip 2)
NO
DO NOT KNOW
COMMENTS:
2. The child/youth requires constant care and supervision in at least one aspect of dressing, eating, toileting, bowel or
bladder control, bathing, menstrual care or personal care (such as grooming activities) .
■ ■
■ ■
■ ■
YES
NO
DO NOT KNOW
COMMENTS:
IMPAIRMENTS IN PHYSICAL COORDINATION AND MOBILITY
3. The child/youth is incapable of movement without assistance which includes any of the following: must be turned,
unable to sit in a wheelchair, requires special lifting equipment, or requires 24-hour frequent repositioning to prevent
decubitus ulcers.
■ ■
■ ■
■ ■
YES (If YES, skip 4)
NO
DO NOT KNOW
COMMENTS:
PAGE 1 OF 3
SOC 837 (11/08)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3