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SCRAPBOOK

 

 1

AFRAID OF NEW SITUATIONS………………………

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 2

WORRIES TOO MUCH…………………………………

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 3

SAD OR UNHAPPY MOST OF THE TIME…………

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 4

SELF-CENTERED OR STUCK UP……………………

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 5

POOR PERSONAL APPEARANCE……………………

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 6

WASTES TIME…………………………………………

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 7

OTHERS TAKE ADVANTAGE OF CHILD…………

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 8

SHY OR TOO QUIET……………………………………

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 9

IMMODEST ABOUT BODY, SHOWS OFF…………

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SETS GOALS TOO HIGH………………………………

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11

DENIES HAVING DONE WRONG……………………

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12

TELLS THINGS THAT DID NOT OCCUR……………

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13

CLINGS TO ADULTS……………………………………

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14

RESTLESS SLEEP………………………………………

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15

HAS TROUBLE FALLING ASLEEP……………………

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CRIES OFTEN……………………………………………

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17

SOILS SELF OR CLOTHING (URINATION OR BOWEL)

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18

WETS THE BED…………………………………………

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19

ACTS OLDER THAN ACTUAL AGE…………………

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20

RESTLESS, OVERACTIVE………………………………

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21

FEELINGS HURT EASILY………………………………

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22

ACTS YOUNGER THAN ACTUAL AGE……………

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23

POOR SELF-IMAGE……………………………………

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24

TAKES CORRECTION POORLY………………………

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25

BLAMES OTHERS FOR MISTAKES…………………

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26

BAD RELATIONS WITH ADULTS……………………

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27

HAS DEPRESSED ATTITUDE…………………………

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28

HAS FREQUENT HEADACHES………………………

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29

COMPLAINS OF ACHES AND PAINS………………

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30

FEELS DEPRESSED A LOT……………………………

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31

MAKES POOR GRADES IN SCHOOL…………………….

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32

FIGHTS AT SCHOOL……………………………………….

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33

DISCIPLINE PROBLEM AT SCHOOL…………………….

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34

DOES NOT COMPLETE HOMEWORK…………………...

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35

STEALS AT SCHOOL……………………………………...

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36

GETS ANGRY EASILY…………………………………….

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37

KEEPS ANGER TO SELF…………………………………..

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38

DOES AS HE/ SHE PLEASES………………………………

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39

STEALS FROM STORES, ETC……………………………..

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40

BAD RELATIONSHIP WITH OTHER KIDS………………

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41

HAS EXPLOSIVE TEMPER TANTRUMS………………...

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42

BULLIES OTHER CHILDREN……………………………..

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43

STEALS AT HOME…………………………………………

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44

USES PROFANITY………………………………………….

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45

ABUSES OBJECTS (FURNITURE, ETC.)…………………

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46

INAPPROPRIATE SEXUAL BEHAVIOR…………………

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47

USES TOBACCO (SMOKES, CHEW, ETC.)………………

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48

USES ALCOHLIC BEVERAGES…………………………..

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49

USES DRUGS (SPECITY________________________)

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50

GANG INVOLVEMENT/ INTEREST……………………...

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51

LACK OF PARENTAL SUPERVISION……………………

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52

NEGLECT……………………………………………………

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53

LACK OF ECONOMIC RESOURCES……………………..

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54

EASILY DISTRACTED……………………………………..

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55

LIKES SCHOOL……………………………………………..

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56

EXHIBITS LEADERSHIP QUALITIES……………………

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57

RESPONSIBLE, FOLLOWS RULES……………………….

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58

CONSIDERATE, HELPFUL………………………………..

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59

AFFECTIONATE……………………………………………

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60

HAPPY GO LUCKY, PLAYFUL…………………………...

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61

ENTERTAINS SELF WELL………………………………..

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10

62

SAD/CRIES………………………………………………….

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10

63

FEELS USELESS, HELPLESS……………………………...

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64

SULKS AND POUTS……………………………………….

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10

 65

WITHDRAWN/PERFERS BEING ALONE………………..

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 66

MOODY/EMOTION SHIFT QUICKLY……………………

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10

 67

NERVOUS, FEARFUL, ANXIOUS………………………...

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10

 68

TOUCHY, RESENTS CRITICISM………………………….

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10

 69

SHOW EMOTION…………………………………………...

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70

BITES NAILS………………………………………………..

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71

GIVES UP EASILY………………………………………….

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72

ARGUES, CRITICIZES OTHERS…………………………..

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73

CURSES, USE ABUSIVE LANGUAGE…………………...

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74

CONS OTHERS/MANIPULATIVE………………………...

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75

DEMANDS ATTENTION…………………………………..

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76

RESENTS DISCIPLINE……………………………………..

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77

SCRATCHES, CUTS OR HURTS SELF…………………

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78

PLAYS WITH FIRE/ MATCHES…………………………..

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79

DISTORTS THE TRUTH……………………………………

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80

CONFUSED, RAMBLED SPEECH………………………

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81

“BORROWS” WITHOUT PERMISSION…………………

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82

MAKES UNUSUAL REPETITIVE MOVEMENTS……….

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83

NERVOUS HABITS (SPECIFY_____________________)..

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84

HITS, FIGHTS, ATTACKS OTHERS……………………

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85

THREATENS TO HURT OTHERS………………………

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86

MAKES FRIENDS EASILY………………………………...

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87

PASSIVE, EASILY INFLUENCED………………………...

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88

WILLING TO SHARE WITH OTHERS……………………

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89

DEFENDS SELF……………………………………………..

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90

FORMS CLOSE RELATIONSHIPS………………………...

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91

VANDALIZES, DESTROYS OBJECTS……………………

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92

USES WEAPONS (SPECIFY______________________)…

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10

93

RUNS AWAY (#_______)…………………………………

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10

94

SNIFFS PAINTS, SOLVENTS, GASOLINE, ETC…………

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95

SMOKES MARIJUANA……………………………………

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10

96

DEALS DRUGS……………………………………………..

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10

97

FORGERY/ THEFT BY CHECK……………………………

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10

98

AUTOMOBILE THEFT……………………………………..

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10

99

IMPULSIVE………………………………………………….

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100

HAPPY TO COME TO THE TIPTON HOME……………..

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10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Text Box: EXPECTATION/ NEED ASSESSMENT
 
WHAT ARE YOUR EXPECTATIONS OF THE TIPTON HOME?______________________________
 
_____________________________________________________________________________________
 
_____________________________________________________________________________________
 
_____________________________________________________________________________________
 
_____________________________________________________________________________________
 
WHAT AREAS DOES THE CHILD NEED HELP WITH?_____________________________________
 
_____________________________________________________________________________________
 
_____________________________________________________________________________________
 
_____________________________________________________________________________________
IF FOR SOME REASON THE CHILD CANNOT STAY AT THE TIPTON HOME PAST THE 30-DAY TRIAL PERIOD OR LATER, WHO WILL COME TO PICK UP THE CHILD?
 
NAME_______________________________________________________________________________
 
ADDRESS____________________________________________________________________________
 
HOME PHONE #_________________________CELL PHONE # _______________________________
 
PAGER #_____________________________WORK PHONE # ________________________________
 
A FRIEND’S #___________________________A NEIGHBOR’S #______________________________
 
EMAIL ADDRESS_____________________________________________________________________
I HEREBY CONFIRM THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE.  
                            ______________________________________________________________________
                                          SIGNATURE OF GUARDIAN                                                                                            DATE
 
                           _______________________________________________________________________
                                          SIGNATURE OF CHILD                                                                                                      DATE

 

  Text Box: HAS THE CHILD BEEN ABUSED?
PHYSICALLY? ____________________________________________________________________________
 
__________________________________________________________________________________________
 
EMOTIONALLY? __________________________________________________________________________
 
__________________________________________________________________________________________
 
SEXUALLY? ______________________________________________________________________________
 
__________________________________________________________________________________________
 
SPIRITUALLY? ____________________________________________________________________________
 
__________________________________________________________________________________________
 
HAS THE CHILD THREATENED SUCIDE? Y N  IF YES, HOW MANY TIMES (_______) PLEASE EXPLAIN____________________________________________________________________________________
 
__________________________________________________________________________________________
 
__________________________________________________________________________________________
 
WHAT WAS HAPPENING WITH THE FAMILY AT THAT TIME? _________________________________
 
__________________________________________________________________________________________
 
__________________________________________________________________________________________
 
__________________________________________________________________________________________
 
__________________________________________________________________________________________
 
HAS THE CHILD RAN AWAY OR THREATENED TO RUN AWAY?  Y  N
IF YES, HOW MANY TIMES (_______) PLEASE  EXPLAIN ______________________________________
 
__________________________________________________________________________________________
 
__________________________________________________________________________________________
 
WHAT WAS HAPPENING WITH THE FAMILY AT THAT TIME? _________________________________
 
__________________________________________________________________________________________
 
__________________________________________________________________________________________
 
__________________________________________________________________________________________
 
 

Text Box: CHILD:
FULL LEGAL NAME____________________________________________________________________________
 
AGE______GRADE_________________DOB_________________BIRTHPLACE___________________________
 
SS NUMBER___________________SEX__________RACE_______________ RELIGION____________________
 
HEIGHT_____________WEIGHT________HAIR___________________EYE COLOR_______________________
 
DISTINGUISHING MARKS_______________________________________________________________________
 
LAST RESIDED WITH_________________________________RELATIONSHIP____________________________
 
ADDRESS_____________________________________________________________________________________
                                                             PHYSICAL ADDRESS                     POSTAL ADDRESS                         CITY                                STATE                                ZIP
 
HOME PHONE______________________________CELL PHONE_______________________________________
 
LEGAL GUARDIAN_____________________________RELATIONSHIP_________________________________
 
ADDRESS____________________________________________HOME PHONE____________________________
 
PRIOR PLACEMENTS (Include foster care, hospitalizations, etc.):
_______________________________________________________________________________________________
                            Name                                                    Address                                                                                                                           Date
 
 
______________________________________________________________________________________________________________________________________________
                            Name                                                    Address                                                                                                                           Date
 
_______________________________________________________________________________________________
                                          Name                                                    Address                                                                                                                           Date
DHS OR CPS CUSTODY________________DATE/S__________________________________________________
 
PLACEMENT REASON_______________________________DISCHARGE REASON_______________________
 
COURT RECORD___________________DATE/S_____________________REASON/S______________________
 
CASE WORKER/PO NAME_______________________________________PHONE #________________________
 
REASON_______________________________________________________________________________________
HOW DOES CHILD FEEL ABOUT PLACEMENT AT TIPTON HOME?
 
_______________________________________________________________________________________________
 
_______________________________________________________________________________________________
PRESENTING PROBLEM:   DESCRIBE REASON FOR PLACEMENT AT THE TIPTON HOME.
 
_______________________________________________________________________________________________
 
_______________________________________________________________________________________________
 

 

 

YES    

 NO

DESCRIPTION AND DATE OF ONSET

ALLERGIES……………………………………………

______

______

__________________________________________________________

ASTHMA   ……………………………………………

______

______

__________________________________________________________

DIABETES  ……………………………………………

______

______

__________________________________________________________

HEART PROBLEMS ……………………………           

______

______

__________________________________________________________

HEARING LOSS  ……………………………                 

______

______

__________________________________________________________

WHOOPING COUGH…………………………………

______

______

__________________________________________________________

SEIZURES………………………………………………

______

______

__________________________________________________________

MEASLES………………………………………………

______

______

__________________________________________________________

EAR TROUBLE…………………………                     

______

______

__________________________________________________________

FAINTING SPELLS ……………………………………

______

______

__________________________________________________________

DIPTHERIA ……………………………………………

______

______

__________________________________________________________

THROAT TROUBLE …………………………………

______

______

__________________________________________________________

CHICKEN POX………………………………………

______

______

__________________________________________________________

MUMPS ………………………………………………

______

______

__________________________________________________________

KIDNEY PROBLEMS …………………………………

______

______

__________________________________________________________

RHUMATIC FEVER…………………………………

______

______

__________________________________________________________

SMALL POX  …………………………………………

______

______

__________________________________________________________

HAY FEVER  …………………………………………

______

______

__________________________________________________________

INFANTILE PARALYSIS……………………………

______

______

__________________________________________________________

SCARLETT FEVER ……………………………………

______

______

__________________________________________________________

HIGH BLOOD PRESSURE…………………………     

______

______

__________________________________________________________

HYPERACTIVE/ADHD……………………………       

______

______

__________________________________________________________

ALCOHOLISM…………………………………………

______

______

__________________________________________________________

AIDS/HIV OR STD’S …………………………            

______

______

__________________________________________________________

TUBERCULOSIS………………………………………

______

______

__________________________________________________________

HEPATITIS A B C…………………………….               

______

______

__________________________________________________________

SEXUAL RELATIONS …………………………           

______

______

__________________________________________________________

ABORTION/S…………………………………………  

______

______

__________________________________________________________

INCESTUOUS RELATIONS ………………………...

______

______

__________________________________________________________

INTRAVENOUS DRUG USE………………………..

______

______

DATE OF LAST USE _______________________________________

HAS CHILD STARTED HER PERIOD YET? ………

______

______