Adoption Post-Placement Visit Note

Date of Visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Assessor Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Assessor Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Address of Visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Child's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Adoptive Parent Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Present at the visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Who else was present for the visit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Medical

Date of child's last well-check {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Completed EPSDT Ohio Well-Checks {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please check all completed exams.

Medical Provider Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Medical Provider Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Medical Provider Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Medical concerns and new information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Observations per JFS 5101:2-48-17(D)(1)

Adoptive Parent(s) response to placement and permanency plan.

If Adoptive Parent(s) are experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Discussion of Adoptive Parent(s) response to placement/permanency plan or red flags from above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Child development, current behavior, and emotional and social functioning in the adoptive home and any other settings

If child is experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Discussion of abnormal developmental observations or red flags from above: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Observed normal development, behavior and social functioning: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Attachment and bonding

If child is experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Discussion of attachment and bonding behavior or red flags from above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

The child's feelings around loss, separation and the reasons for being adopted.

Narrative: (4 years and up) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Changes in the Adoptive Home/Family per JFS 5101:2-48-17(D)(2)

Check all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Discussion of all changes checked above: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Additional Information: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Future Follow-Up and/or Action Steps {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Signature and Credentials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

By selecting the "SUBMIT" button, you are signing this Adoption Post-Placement Visit Note electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Note. By selecting "SUBMIT" you are ensuring that you are the author of this note.

Adoption Post-Placement Visit Note

Date of Visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Assessor Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Assessor Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address of Visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Child's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Adoptive Parent Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Adoptive Parent Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Present at the visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Who else was present for the visit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Medical

Date of child's last well-check {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Completed EPSDT Ohio Well-Checks {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical Provider Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical Provider Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical Provider Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical concerns and new information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Observations per JFS 5101:2-48-17(D)(1)

Adoptive Parent(s) response to placement and permanency plan.

If Adoptive Parent(s) are experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Discussion of Adoptive Parent(s) response to placement/permanency plan or red flags from above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Child development, current behavior, and emotional and social functioning in the adoptive home and any other settings

If child is experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Discussion of abnormal developmental observations or red flags from above: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Observed normal development, behavior and social functioning: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Attachment and bonding

If child is experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Discussion of attachment and bonding behavior or red flags from above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

The child's feelings around loss, separation and the reasons for being adopted.

Narrative: (4 years and up) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Changes in the Adoptive Home/Family per JFS 5101:2-48-17(D)(2)

Check all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Discussion of all changes checked above: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Additional Information: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Future Follow-Up and/or Action Steps {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Signature and Credentials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

By selecting the "SUBMIT" button, you are signing this Adoption Post-Placement Visit Note electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Note. By selecting "SUBMIT" you are ensuring that you are the author of this note.

Adoption Post-Placement Visit Note

Date of Visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Assessor Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Assessor Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address of Visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Child's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Adoptive Parent Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Adoptive Parent Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Present at the visit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Who else was present for the visit? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Medical

Date of child's last well-check {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Completed EPSDT Ohio Well-Checks {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical Provider Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical Provider Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical Provider Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Medical concerns and new information {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Observations per JFS 5101:2-48-17(D)(1)

Adoptive Parent(s) response to placement and permanency plan.

If Adoptive Parent(s) are experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Discussion of Adoptive Parent(s) response to placement/permanency plan or red flags from above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Child development, current behavior, and emotional and social functioning in the adoptive home and any other settings

If child is experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Discussion of abnormal developmental observations or red flags from above: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Observed normal development, behavior and social functioning: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Attachment and bonding

If child is experiencing any of the following, consider this a red flag: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Discussion of attachment and bonding behavior or red flags from above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

The child's feelings around loss, separation and the reasons for being adopted.

Narrative: (4 years and up) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Changes in the Adoptive Home/Family per JFS 5101:2-48-17(D)(2)

Check all that apply: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Discussion of all changes checked above: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Additional Information: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Future Follow-Up and/or Action Steps {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Signature and Credentials {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date of Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

By selecting the "SUBMIT" button, you are signing this Adoption Post-Placement Visit Note electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Note. By selecting "SUBMIT" you are ensuring that you are the author of this note.