Central Auditory Processing Disorder - DOC by Ma5vn8


									                North Carolina Division of Social Services in contract with North Carolina Kids Adoption & Foster Care Network
                   NC Kids/UNCG ~ P.O. Box 26170 ~ Greensboro, NC 27402-6170 ~ 336-315-7475 ~ FAX 336-315-7479

                                                       CHILD REGISTRATION FORM
Use this form to register legally free children (if not legally free, use DSS-5225). Please type or print. ALL INFORMATION MUST BE
COMPLETED. If any item is not applicable, write N/A. If using automated version, upon completion change file name and save to your
PC for future use. Please send one copy of completed form to the above address with one copy of the child’s summary and a picture.
   New Registration   Annual Update
                                                           FAMILY PREFERENCES
SIS Number                                                                            I. Family Type
                                                                                          No preference                       Two Parent Family
Name                                                                                      Single Parent-Female                Male/Female
                                                                                          Single Parent-Male                  Female/Female
First                         Middle          Last
                                                                                      II. Sibling Preferences
Date of Birth                                 Gender                                       No preference           Must be youngest
                       (mm/dd/yy)                                                          Female siblings only    Male siblings only
                                                                                           No other children       Must be oldest
Ethnicity                                                                                 Would benefit from other children in the home

    Not in School                   Preschool           Special Education                       PLACEMENT HISTORY
    Ungraded School                 Attending Special Resource Classes                Date Entered Foster Care
Grade (check one):                                                                    Date Legally Free
K       1   2      3      4    5     6    7     8      9 10    11 12
                                                                                      Number of Placements
                                                                                      Current Placement Date
                SIBLING INFORMATION                                                   Current Placement Type
T=To be placed together                       S=To be placed separately               No. of Adoption Disruptions
                  Children                             T S Date of Birth
Name                                                                                  ADOPTION ASSISTANCE                             Yes     No
SIS#                                                                          Monthly Cash Payment
Name                                                                          Medicaid
SIS#                                                                          Medical Vendor
Name                                                                          Remedial/Therapeutic Vendor
SIS#                                                                          Non-Recurring Costs
Name                                                                          HIV+ Supplement
SIS#                                                                              Adoption Funding Source                 IV-E         IV-B
                                                                                 OTHER ASSISTANCE OFFERED                             Yes     No
                                                                              Purchase of Service (above standard $1,800)
If separated, what is the recommended frequency of contact?                   If yes, up to amount $      ____________
            None                                     Daily                    Transportation for child to visit prospective family
            Weekly                                   Monthly                  If yes, up to amount $        ____________
            Yearly                                   Other                    Transportation for prospective family to visit child
                                                                              Monthly Cash Paymebn
                                                                              If yes, up to amount $       ____________
  DSS-1820 (Rev. 7-02)                                                        Medical Vendor
  Page 1 of 4
  Children’s Services                                                         Remedial/Therapeutic Vendor
                                                                              Non-Recurring Costs
                                                                              HIV+ Supplement
                                          SPECIAL NEEDS INFORMATION
                        Must be diagnosed and/or documented in case file. Please check all that apply.

1 = None     2 = Mild
3 = Moderate 4 = Severe                       None                                          None
                                              Allergies                                     Down Syndrome
Physical                                      Asthma                                        Lead Poisoning
Emotional                                     AIDS/HIV                                      Microcephalus
Learning                                      Autism                                        MR - Not specified
Mental Retardation
                                              Blindness/Visual Impairment                   MR - Genetic
EMOTIONAL DISABILITIES                        Cancer                                        Phenylketonivia (PKU)
                                              Cerebral Palsy                                Prader Willi Syndrome
                                              Congenital Heart Disease                      Shaken Baby Syndrome
   Adjustment Disorder
                                              Cystic Fibrosis                               Trisomy 13
                                              Deaf/Profound Hearing Loss                    Trisomy 18
   Attachment Disorder
                                              Developmental Disabilities                    William Syndrome
   Behavior Problems
                                              Diabetes                                      Other
   Bulimia                                                                               RISK FACTORS
   Conduct Disorder
                                              Epilepsy                                      None
   Cruelty to Animals
                                              Failure to Thrive                             Alcohol Exposed
                                              Fetal Alcohol Effect                          Drug Exposed
   Developmental Disabilities
                                              Fetal Alcohol Syndrome                        HIV Exposed
                                              HIV Positive                                  Lead Poisoning
   Emotional Problems
                                              Hearing Loss - Partial                        Domestic Violence in Birth Family
   Fire Starter
                                              Heart Defect                                  Mental Illness in Birth Family
   Loss Issues
                                              Heart Murmur                                  Mental Retardation in Birth Family
                                              Hydrocephalus                                 Neglected
   Obsessive Compulsive Disorder
                                              Hyperactivity                                 Physically Abused
   Oppositional Defiant Disorder
                                              Hypertension                                  Premature Birth
   Physically Aggressive
                                              Kidney Disease                                Schizophrenia in Birth Family
                                              Medically Fragile                             Sexually Abused
   Post Traumatic Disorder
                                              Microcephalus                                 Other
   Post Traumatic Stress Disorder
                                              Missing Limb(s)
   Property Damage
                                              Multiple Sclerosis
   Psychosis                                                                           Please list any medications this child is taking:
                                              Muscular Dystrophy
   Reactive Attachment Disorder
   Run Away
   Self Abusive
   Sexually Acting Out
                                              Sexual Transmitted Disease
   Takes Psychiatric Medication
                                              Seizure Disorder
                                              Sickle Cell Anemia
                                              Sickle Cell Trait                        Please comment on any special need you think
   None                                       Speech Disorder                          might benefit from additional explanation
   Aphasia                                    Spina Bifida                             (i.e., frequency, severity, etc.):
   Attention Deficit Disorder                 Terminal Illness
   Attention Deficit Hyperactivity            Tourette Syndrome
   Central Auditory Processing Disorder
                                              Total Care Required
   Developmental Articulation Disorder
   Dyslexia                                   Trach Syndrome
   Expressive Language Disorder               Tube Feeding
   Learning Disability                        Visual Impairment
   Motor Skills Disorder                      Other
   Non-specific Learning Disorder
   Receptive Language Disability

 DSS-1821 (Rev. 7-02)
 Page 2 of 4
 Children’s Services
                                               CHILD SPECIFIC QUESTIONS
Please list the child's favorite under each heading in this table.
     School        Afterschool     Sports to     Toys/Games      Hobbies or   Vacation Spot/   Movie or TV   Foods to Eat    Music or
    Subjects          Clubs       Play/Watch                     Activities   Family Outing      Show                       Music Group

Describe any physical or mental limitations this child has:

Describe any behavioral or emotional challenges this child has:

List any area the child is especially good at or would like to try:

What does the child want to be when he/she grows up?

What are the child's feelings about adoption and the kind of family he/she wants?

DSS-1821 (Rev. 7-02)
Page 3 of 4
Children’s Services
  Please gather specific quotes from foster parents, teachers and other adults involved with this child. What do they like best about this
  child? What does this child need help with? Please specify who offered the quote:

   What particular training, skills, experience, qualities or post adoption access to services should this child’s new family have?

~~~      PHOTO
     One copy of a clear                  I give permission to NC Kids Adoption Foster Care Network to use the
     picture of this child or             description and picture of this child in recruitment efforts to find a home. I
     sibling group MUST be                understand that all approved families referred to my agency must be
     submitted along with                 considered as possible placements, regardless of location, nationality, or race
     this registration form.
     School portraits or
                                          of family, unless the child's permanency plan indicates otherwise and is pre-
     35mm photos are                      approved by the state office.
     acceptable. DO NOT
     send Polaroid photos.               Agency Representative Signature
     DO NOT STAPLE                                                                                                       Date
     PICTURE to form.
     Digital pictures are                  Contact Person:
     acceptable. Place jpeg
     on disk and submit with               Agency Name:
     application (or e-mail to             Address:

           PROFILE                         Telephone:                                              Fax:
     One copy of the child’s               E-mail:
     pre-adoptive profile
     MUST be submitted                     Social Worker:
     along with this                       (if different than above)
     registration form.                    Telephone:                                              Fax:
     DSS-1821 (Rev. 7-02)
     Page 4 of 4
     Children’s Services

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