Adoption Post-Placement Visit Note

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Present at the visit
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Medical
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Completed EPSDT Ohio Well-Checks
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Please check all completed exams.
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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:
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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:
{ binding firstError.message }
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Attachment and bonding
If child is experiencing any of the following, consider this a red flag:
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The child's feelings around loss, separation and the reasons for being adopted.

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

Check all that apply:
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{ binding firstError.message }
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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
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Assessor Name
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Assessor Email
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Address of Visit
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Child's Name
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Adoptive Parent Name
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Adoptive Parent Name
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Present at the visit
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Who else was present for the visit?
Medical
Date of child's last well-check
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Completed EPSDT Ohio Well-Checks
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Medical Provider Name
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Medical Provider Address
{binding displayValue}
Medical Provider Phone
{binding displayValue}
Medical concerns and new information

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:
{binding displayValue}
Discussion of Adoptive Parent(s) response to placement/permanency plan or red flags from above.

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:
{binding displayValue}
Discussion of abnormal developmental observations or red flags from above:
Observed normal development, behavior and social functioning:
Attachment and bonding
If child is experiencing any of the following, consider this a red flag:
{binding displayValue}
Discussion of attachment and bonding behavior or red flags from above.

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

Narrative: (4 years and up)
{ binding firstError.message }

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

Check all that apply:
{binding displayValue}
Discussion of all changes checked above:
{ binding firstError.message }
Additional Information:
Future Follow-Up and/or Action Steps
Signature and Credentials
Date of Signature
{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
{binding displayValue}
Assessor Name
{binding displayValue}
Assessor Email
{binding displayValue}
Address of Visit
{binding displayValue}
Child's Name
{binding displayValue}
Adoptive Parent Name
{binding displayValue}
Adoptive Parent Name
{binding displayValue}
Present at the visit
{binding displayValue}
Who else was present for the visit?
Medical
Date of child's last well-check
{binding displayValue}
Completed EPSDT Ohio Well-Checks
{binding displayValue}
Medical Provider Name
{binding displayValue}
Medical Provider Address
{binding displayValue}
Medical Provider Phone
{binding displayValue}
Medical concerns and new information

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:
{binding displayValue}
Discussion of Adoptive Parent(s) response to placement/permanency plan or red flags from above.

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:
{binding displayValue}
Discussion of abnormal developmental observations or red flags from above:
Observed normal development, behavior and social functioning:
Attachment and bonding
If child is experiencing any of the following, consider this a red flag:
{binding displayValue}
Discussion of attachment and bonding behavior or red flags from above.

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

Narrative: (4 years and up)
{ binding firstError.message }

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

Check all that apply:
{binding displayValue}
Discussion of all changes checked above:
{ binding firstError.message }
Additional Information:
Future Follow-Up and/or Action Steps
Signature and Credentials
Date of Signature
{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.