Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-E
Identifying Information
* Name
* Race
* Birthplace
* Current placement
* Physical description of child/youth
* Age (identify developmental issues that may have affected or are affecting this child/youth.
Legal Status
* State the reason the child/youth was removed from the birth family
* Describe efforts to be made or that have been made to reunite the child/youth with birth family.
* Identify why efforts are not being made or were not made to reunify the child/youth with the birth family. (per ASFA)
* Describe, if relevant, events leading to TPR/permanent wardship.
Physical Description
* Describe the child/youth's physical appearance, such as height and weight, hair color, eye color, etc.
* Indicate any outstanding or unusual features or birthmarks.
* Describe the child/youth's level of physical functioning and activity.
Culture
* What is the child/youth's religion?
* What is the child/youth's cultural background?
* What ethnic/cultural group does the child/youth identify?
* What experiences has the child/youth had with this ethnic/cultural group?
* Which language(s) does the child/youth speak or understand?
* Which cultural traditions, values and beliefs are important to the child/youth?
Daily Routine
* Describe the child/youth's daily routine.
* List the child/youth's favorite books, toys and games, foods, possessions, hobbies, interests, and special activities.
* Identify any special pet the child/youth has or had.
* Describe the child/youth's level of care of possessions.
* List suggestions that the child/youth's current caregiver has for future caregivers regarding what works best for this child/youth in terms of daily routine.
Placement History (Child/Youth's Placement History Summary)
* List the child/youth out-of-home placements (where, when and the age of the child/youth at the time of placement), including those occurring prior to entry into care (with relatives, hospitalizations etc.)
* Identify significant people and events in the child/youth's life, explaining each relationship and what happened.
* Explain the child/youth's perception of these events and relationships; for example, describe the messages to the child/youth.
Family History (Genogram)
Birth Family
* Family history information based on interviews with family members, current and prior caregivers, information from records, the initial service plan for the child/youth/family, etc.
* Factual, historical information about family members, including birth dates, physical descriptions, health information, relationship with the child/youth.
* Parents' and siblings' birth dates, ethnicity and last known location.
* Identify extended family members with whom the child/youth has had or has expressed an interest in having ongoing contact.
* Identify any extended family members who may be available for permanency planning or permanency supports.
Siblings
* Indicate the current status of all siblings. Are they with parents, relatives, in placement, previously adopted, etc.?
* Indicate whether the siblings are in care; placed in same family as the child/youth; or if not placed with this child/youth, why the child/youth and sibling(s) were not placed together and should not be placed together in adoption.
* What are the permanency plans for other children?
* What is or will be the plan for contact between siblings?
* What is the expectation or plan for parental and sibling visitation if the permanent plan for this child/youth is not to return home or be placed with siblings?
* If the child/youth has sibling-like relationships with children/youth who are not related by birth, describe each relationship and the plans for future contact.
Perception of Birth Family
* Define the child/youth's own understanding of why he/she was removed from the home and the permanent plan made for the child/youth.
* Indicate whether the child/youth currently has contact with the birth family.
* List the child/youth's stated feelings about the birth family.
* List the Worker's impressions of the child/youth's true feelings about the birth family.
* What issues need to be addressed prior to and after the permanent placement, such as closed, open, or semi-open adoption?
* What can adoptive parent(s) or other permanent family expect in terms of the child/youth's attachment to the birth family?
* If not returned to parent(s), what interest does the child/youth have in locating birth parents, either now or in the future?
* If the child/youth has a significant relationship with another family (relative, foster parent, etc.) describe the child/youth's perception of this relationship, possibility of permanency in this relationship, and plans for contact once the permanent plan is implemented (if not with this relationship).
Relationships
Adult
* Describe the child/youth's interaction with birth parents during visits, or the nature of past visits with the parents if there is no contact with them at this time.
* Who are the significant adults in this child/youth's life?
* Are any of the adults someone whom the child/youth considers as a" psychological parent"?
* How does the child/youth relate to the significant adults in his/her life and to strangers?
* How does the child/youth seem to express any significant differences in relating to males or females?
* How does the child/youth relate to authority figures, such as teachers, counselors, therapists, Worker, etc.?
Others Living in the Child/Youth's Home
* Indicate the child/youth's interaction pattern with other persons living in the home/residential setting.
* Are there persons to whom the child/youth feels closer to than others?
* Does the child/youth react to other children/youth being placed or leaving the foster home/residential setting? If so, how?
Peers
* What is the child/youth's interactions with peers:
* Describe any differences between the child/youth's interactions with school and neighborhood peers.
* Does the child/youth relate better to children/youth who are younger, older, or the same age?
* Is there a significant difference in relating to male and females?
* Does the child/youth relate better in large groups, small groups, or one on one?
* Does the child/youth have one or two special friends?
* Does the child/youth make friends easily, or is he/she a loner?
Community
* Is the child/youth involved in community or social activities such as YWCA/YMCA, Girl/Boy Scouts, sports, band, dance, etc.?
* Does the child/youth identify with a specific community?
* Are there any other special relationships that the child/youth has in the community (church, teachers, etc.)?
Medical History
* Indicate all significant medical information on the child/youth including birth history and a record of the child/youth's immunizations. (Ensure that medical records are in the child/youth's file.)
* When was the child/youth's most recent physical examination?
* Are there any medical issues that require follow-up?
* Does the child/youth have any physical conditions requiring ongoing attention?
* Indicate any known family illnesses or history of disease, such as heart problems, high blood pressure, diabetes, sickle cell anemia, etc.
* Describe the child/youth's dental health.
* Are there any dental needs that require follow-up such as braces, filling of cavities, or treatment of gum disease?
* What is the child/youth's level of eyesight, hearing, etc.?
* Is there a need for corrective lenses or hearing aid?
* List all injuries with dates, treatment, and long-term impact.
Developmental History
* Indicate developmental milestones. Were they age appropriate?
* Indicate any developmental delays or reactions to stress.
Sexual Development
* Indicate age appropriateness of the child/youth's sexual development.
* Is there a known history of sexual abuse?
* Is there a suspicion of sexual abuse?
* Is there a history of sexual acting out? (be specific) If so, has treatment been provided?
* Is there a current pattern of sexual acting out? If so, has treatment been provided?
* What is the child/youth's level of understanding of sexual behavior?
* What have been the child/youth's sexual experiences? Are they age appropriate?
* Are there any sexual identity issues with this child/youth?
Academic Functioning
Educational History
* What is the child/youth's educational history? (Be as specific as possible where and when the child/youth has attended school, starting with preschool. List reasons for changes in school.)
* What was the child/youth's level of scholastic achievement in each grade?
* Has special education ever been recommended? If so, has it been provided?
* What is the reason for special education?
* Is there a copy of a past testing or past IEP in the child/youth's file?
Current School Placement
* Indicate the name of the child/youth's school, grade and teacher(s).
* Is there a school social worker involved with the child/youth?
* What are the child/youth's strengths and weaknesses in academic functioning?
* What are the child/youth's academic interest?
* What are the child/youth's most recent report card grades?
* Would the child/youth benefit from academic tutoring?
* If the child/youth has been placed in special education, when was this determination made?
* What was the date of the child/youth's most recent IEP consultation testing?
* What special educational services are needed?
* What special educational services are provided?
* What is the child/youth's level of accomplishment?
* Is there a current IEP in the child/youth's file?
Testing
* Indicate results of all testing done with this child/youth. (Ensure that copies of test reports are included in the child/youth's record.)
* Who was the examiner? When and where was the testing completed? What were the findings?
* Is there a need for further testing of the child/youth?
Educational Plan
* What are this child/youth's educational goals or projection for the future?
* What do the child/youth's current family and eventual permanent family need to do to assist the child/youth in meeting educational needs or projections?
* Also, note whether or not the child has developed a strong and positive relationship in the academic environment.
Emotional Functioning
* Give a brief history of the emotional development of the child/youth.
* How are the child/youth's emotional history and experiences impacting current behavior?
* What might the child/youth's permanent family expect in the future as a result of early experiences in the birth family, such as violence, neglect and the number and types of moves.
* What is the child/youth's self-image?
* What is the child/youth's level of self-esteem?
* Describe times or situations in which the child/youth regresses, is afraid, experiences loneliness, withdraws, is aggressive, or acts out.
* Describe what the child/youth needs from a parent (what type and amount of affection, attention, discipline, need for closeness or distance, bedtime preparation, support during night fears).
* What are the child/youth's relationships with adults and peers?
* Indicate the child/youth's existing attachments.
* With whom or what has the child/youth had a prior emotional attachment?
* How has the child/youth dealt with separation from these people/places/things?
* Is there evidence that the child/youth has difficulty with attachment?
* Which defenses does the child/youth employ to cope with strong feelings of anger, rejection, abandonment, separation/attachment etc.?
* Does the child/youth play appropriately with children/youth of the same age?
* Does the child/youth act out behaviorally in the foster home/residential setting? What is the acting out behavior?
* Is there a history of lying, stealing, fire setting or any destructive behaviors with the child/youth? If so, what has been done to address these behaviors?
* What is the child/youth's sense of right and wrong?
* What is the child/youth's level of cooperation and attention span?
* What controls need to be in place for this child/youth?
* Has the child/youth been in therapy? If so, when and where?
* If the child/youth is or has been in therapy, who is the therapist; and what are the findings and recommendations? (Note any testing, medication, psychiatric history.)
* What does the child/youth need in order to separate from current caregiver, if possible?
* What is the child/youth's level of emotional functioning?
Attitude Toward and Readiness for Adoption
* What are the child/youth's stated feelings about returning home or another permanent placement?
* Has the child/youth identified any preferences and concerns about placement? If so, what are these?
* Has the child/youth identified any situations and placements that would make her/him most comfortable? If so, what are those?
* What is the child/youth's understanding of permanency options: return home, relative or foster care, adoption and how each of these placement options does or does not provide permanency for him/her?
* What is the child/youth's ability to attach to new parents and at what level can the child/youth attach?
* Which services are needed to prepare the child/youth for placement with a permanent family?
Financial Supports for Child Following Adoption
* Child's certification for Adoption Assistance based on special needs
* Social Security benefits (SSDD or SSI)
* Veteran's Benefits
Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-E