DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence Intake Information Group Home Resident Under 6 Years of Age Use of form: Use of this form is voluntary. Group homes may use this form to collect the assessment information DCF 57.23(1)(a) needed to complete the treatment plan required under DCF 57.23(2) and 57.37(3) of the Wisconsin Administrative Code. Personally identifiable information gathered on this form is confidential and will be used for identification purposes only. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. Complete this form as a supplement to the DCF-F-CFS2382A-E, Intake Information Group Home Resident. If additional space is needed when completing this form, Instructions: – attach separate sheets. Name Child Birthdate (mm/dd/yyyy) Date Form Completed (mm/dd/yyyy) – A. FEEDING, TYPES OF FOOD INTRODUCED AND MEALS Current Feeding Schedule Length of Time on Current Schedule New Food Timetable Food Type: Formula specify brand. Type of formula. Powder Concentrate Ready-to-feed – Milk specify type. – Strained Junior Table When eating, the child is: Held in lap In highchair Other specify. – Yes No Does child feed self? If child uses: Hands Spoon Fork “Yes”, Yes No Special feeding problems? If “Yes”, specify. Yes No Food allergies? If “Yes”, specify. Favorite foods specify. – Refused foods specify. – Special diet needs (e.g., religious, medical, etc.) specify. – B. DIAPERING AND TOILETING PROCEDURES / SPECIAL TOILETING NEEDS Diaper type Diapers provided Highly sensitive skin Plastic pants used Always Never Sometimes specify: Cloth Disposable Yes No Yes No – Frequent diaper rash Yes No Oil, powder or lotion used If specify. “Yes”, Yes No Yes No Toilet training attempted? If describe routine. “Yes”, Type of toilet seat used at home Potty chair Special toilet seat Regular toilet seat – Yes No Regular bowel movements If how often: Times of day “Yes”, – Yes No Toileting problems If describe. “Yes”,
DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence Intake Information Group Home Resident Under 6 Years of Age Use of form: Use of this form is voluntary. Group homes may use this form to collect the assessment information DCF 57.23(1)(a) needed to complete the treatment plan required under DCF 57.23(2) and 57.37(3) of the Wisconsin Administrative Code. Personally identifiable information gathered on this form is confidential and will be used for identification purposes only. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. Instructions: Complete this form as a supplement to the DCF-F-CFS2382A-E, Intake Information – Group Home Resident. If additional space is needed when completing this form, attach separate sheets. Name – Child Birthdate (mm/dd/yyyy) Date Form Completed (mm/dd/yyyy) A. FEEDING, TYPES OF FOOD INTRODUCED AND MEALS Current Feeding Schedule Length of Time on Current Schedule New Food Timetable Food Type: Formula – specify brand. Type of formula. Powder Concentrate Ready-to-feed Milk – specify type. Strained Junior Table When eating, the child is: Held in lap In highchair Other – specify. Yes No Does child feed self? If “Yes”, child uses: Hands Spoon Fork Yes No Special feeding problems? If “Yes”, specify. Yes No Food allergies? If “Yes”, specify. Favorite foods – specify. Refused foods – specify. Special diet needs (e.g., religious, medical, etc.) – specify. B. DIAPERING AND TOILETING PROCEDURES / SPECIAL TOILETING NEEDS Diaper type Cloth Disposable Diapers provided Yes No Highly sensitive skin Yes No Plastic pants used Always Never Sometimes – specify: Frequent diaper rash Yes No Yes No Oil, powder or lotion used If “Yes”, specify. Yes No Toilet training attempted? If “Yes”, describe routine. Type of toilet seat used at home – Potty chair Special toilet seat Regular toilet seat Yes No Regular bowel movements If “Yes”, how often: Times of day – Yes No Toileting problems If “Yes”, describe.
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