Birth & Beyond Community Response - DOC by hZxpAYlJ


									Birth & Beyond Community Response
Case Closure Form                                                                                                        Community Response

 Family Name:                                                    Family ID:                          Staff Name:

 Intake Date:                                               SERVICE:          0   B&B HV        1   DR     6   IS    8   FRC Case Mgmt
 Closure Date:                                                   Date of last face to face contact:
 CPS Referral #:                                                    Baby not born before Closure date.
 DR Contact Level:          1    1-3 Home visits w/FRC referral        2   4-12 Home visits w/ FSP         3 13-24   Home visits w/ FSP
 How many children ages 3-5 enrolled in Early Childhood Education, Pre-Kindergarten, or Head Start: ______
 Progress towards Family Support Plan:                 1 None         2 Minimal         3 Significant          4 Goal(s)   Accomplished
 Keep family active for FRC Services?         1 Yes     2 No
 If No, give reason (First 5 criteria): Completed program                         Dropped out            Moved             Lost Contact
 Reason for Closure (select one)
     0 CWS case opened for services                                               7 No contact after 4 face to face attempts
     1 PHN case opened for services                                               8 No longer Eligible (aged out, jail, residential tx)
     2 Child removed from home                                                    9 Transferred to another BBCR site*
     3 Declined further services/no longer available                              11 No birth/miscarriage
     5 Moved out of service area                                                  12 Completed program as planned

 For TRANSFER Cases Only
 Original BBCR site: Select One                                   Staff who contacted receiving site:
 *Receiving BBCR site: Select One                                                     Received by Staff:
 Copies of forms in TRANSFER packet:                     Initial Referral From                Consent to Release/Exchange
 Date Transfer packet received:                         Date original site notified of receipt:
 Date of joint visit between home visitors:


 _____________________________________________________                                                     _____/_____ /_____
 Original Staff Signature                                                                                  Date

 _____________________________________________________                                                     _____/_____/______
 Original Supervisor Signature                                                                             Date

 DATA Entry Completed by:                                                                                  Date:           /      /
Place copy of the Case Closure Form in client case file, top right. File with Closed Files.

                                                                                                                           Instructions on back.
REV Approved by PMOC 11/17/09
Section 6.10.1
Birth & Beyond Community Response
Case Closure Form                                                                        Community Response

The Case Closure Form is to be use in the event of two circumstances 1) the family case is closed or 2) the
family case is transferred to another Birth & Beyond Community Response (BBCR) site. When transferring
a case to another BBCR site, continuity of care is essential to the quality of services provided.
    1. Information required for case maintenance and data entry
           Family name and ID
           Staff name
           Intake date (mm/dd/yy)
           Select the service type the family is being closed from.
           Closure date (mm/dd/yy)
           Date of last face to face contact; reference Face-to-Face form for date (mm/dd/yy)
           CPS Referral #
           Indicate if the case was closed before the baby was born.
           Indicate level of contact provided for differential response (DR) referred families. Leave
             blank if service type was other than DR.
           Indicate number of children 3-5 enrolled in early education upon closure.
           Check progress accomplished towards Family Support Plan.
           Check whether or not the family will continue with FRC services.
    2. Case Closure
           For FRC families, select one of the First 5 criteria as a reason for closure.
           For all other service types, indicate reason for case closure. Check one box.
           Review and update all case activity documentation, including; Face to Face, Service Activity
             Log, the case file checklist and any other pertinent information.
           The Case Closure Form must be completed within five (5) working days and placed in the
             case file.
    3. Case Transfer
           At the family’s request, the originating BBCR service provider will assist in the transfer of
             families who relocate to another BBCR zip code service area.
           Indicate reason for closure at “Transferred to another BBCR site”.
           The original BBCR supervisor will have a person-to-person contact with the receiving BBCR
             supervisor, acknowledging acceptance before transfer.
           Ensure that family signs required consent for transferring case files to a new service
           The family’s case must be closed at the original site.
           The originating BBCR site will fax a transfer packet consisting of: the initial referral form,
             current consent forms and the Closure Form.
           Within five (5) working days of faxing the transfer packet, a copy of the entire family case
             file content must be mailed to the receiving BBCR site.
           The receiving site will acknowledge the receipt of the transfer packet via fax or email, in
             addition to documenting the date on the Case Closure form.
           As a best practice, the original and new home visitors will schedule a joint visit to facilitate
             the successful transition of the family to the new provider.
    4. Supervision
           Case closure and case transfers, must be staffed in supervisor before any action is taken.
           The Case Closure Form is to be signed by the original primary staff person and the
           For DR families; a copy of the signed form is to be faxed to Child Welfare Services for the
             family case file. FAX: (916)875-5211.

REV Approved by PMOC 11/17/09

To top