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
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Medical Provider Phone
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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:
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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:
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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:
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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)
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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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Discussion of all changes checked above:
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Additional Information:
Future Follow-Up and/or Action Steps
Signature and Credentials
Date of Signature
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