CMS-07-021/023 - Los Angeles County Department of Children and ...

DISCHARGE SUMMARY FOR DCFS: FOSTER FAMILY AGENCY 1
1. What was the reason for the child’s exit from the certified family home?
2. Who determined the child was ready to leave the certified family home?
3. Was the child discharged to Permanency?
Yes [ ] No [ ]
If “yes,” check one: Reunification [ ] Adoption [ ] Legal Guardian [ ]
Provide the address to which the child was discharged, if available:
4. Was the child discharged according to their Permanency Plan?
Yes [ ] No [ ]
5. Was the child discharged to a less restrictive environment?
Yes [ ] No [ ]
If “yes” indicate whether to: Parent(s) [ ] Relative Home [ ] FFH [ ]
SFH [ ] 2
6. Did the child meet their Needs and Services Plan goals prior to discharge?
ILP/Emancipation goals: Yes [ ] No [ ]
Educational goals: Yes [ ] No [ ]
Mental Health Treatment goals: Yes [ ] No [ ]
7. What was the agency’s assessment of the child’s level of functioning upon
discharge?
8. What was the Agency’s recommendation for continued services for the child
(individual/conjoint counseling, special education services, etc.)?
EXHIBIT Z
1 For DCFS Placed Children, complete and send to DCFS Out of Home Care Management, Division
Chief, 9320 Telstar Avenue, Suite 216, El Monte, CA 91731. For Probation youth, contact the Central
Placement OHC Unit at (323) 226-8600.
2 FFH (foster family home); SFH (small family home).
EH:wh 4-16-07