Animal Allergies-Severe Asthma-Severe Drug Allergies-Severe Environmental Allergies Food Allergies-Severe
Aggressive to Other Children Defiant Difficulty in Attaching Difficulty Making Friends Encopresis Enuresis Lying Manipulative Poor Social Skills Self-Abuse Stealing Suicidal Attempts Tantrums-Severe Wets the Bed
Born with HIV issues Drug Addicted at Birth Failure to Thrive Fetal Alcohol Effected Low Birth Weight or Prem Prenatal Drug Exposure
Gastric Tube Requires Life Long Medical Requires Life Long Superv Tracheotomy
Non-Ambulatory Occupational Therapy Physical Therapy Physically Disabled-Mild Physically Disabled-Severe
Blind Deaf Hearing Impaired Intellectual Disability - Mild Intellectual Disability - Moderate Intellectual Disability - Severe Speech Delays - Mild Speech Delays - Moderate Speech Delays - Severe Vision Impaired
Anorexia/Bulimia Hoarding Overeating Pica
Behind because Attendance Cognitive Delay - Mild Cognitive Delay-Severe Expulsion(s) Has Behavior Probs. in School Mild Learning Disabilities Moderate Learning Disabilities Severe Learning Disabilities Speech/Lang Impairment Suspension(s)
1/2 Par. Diag. Depression 1/2 Par. Diag. Schizoph. 1/2 Par. Have Alcohol Addic 1/2 Par. Have Drug Addic 1/2 Parents Diag Bipolar Exposed to Dom Violence Parent(s) had Mental Diag
Child in Residential Treatment Residential Treatment History Had a Disrupted Adoption Multiple Placements Will Seek Guardianship Only
Child on Prob/Parole Convicted of Theft Previously Incarcerated
Limited Life Expect Terminally Ill(1 Y.)
ADHD AIDS Arthritis Cancer Cerebral Palsy Cystic Fibrosis Diabetes Down Syndrome Epilepsy Heart Disorder (Pos Surgery) Hemophilia HIV Missing Limbs (Pos Prosth.) Muscular Dystrophy Seizures Sickle Cell Disease Sickle Cell Traits Spinal Bifida
Schizophrenia Adjustment Disorder Aspergers Syndrome Autism Bipolar Disorder Conduct Disorder Depression Intermittent Explosive Disorder Oppositional Defiant Disorder Post Traumatic Stress Disorder Previous Psychiatric Hosp Reactive Attachment Disorder Req. Med. For Psych. Cond/Diag. Requires Counseling/Therapy
Animal Abuse Destructive of Property Fire Starting Runaway Runaway - Past
Contact via mail Contact with Foster Parent Contact with Relatives Contact with Siblings
History of Sexually Acting Out Sexually Abused in the Past Sexually Active Child Identifies as LGBT
Alcohol Use Marijuana Smokes Cigarettes