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STATE OF NEW HAMPSHIRE

Department of Health and Human Services

Form 2281

Division for Children, Youth and Families

October 2010

DCYF YOUTH INFORMATION SHEET

Date Completed

Bridges Client ID #

IDENTIFYING INFORMATION:

Youth’s Name

DOB:

SSN

Address

Home Phone

Town

State

Zip

Cell Phone

Previous Address

E-Mail

Town

State

Zip

Gender

Height

Weight

Eye Color

Hair Color

Scars, Marks, Piercings, Tattoos:

Complexion

Birth place

Religion

Current religious/cultural practices

Ethnicity (Check all that apply)
American Indian/Alaskan Native	Hispanic Origin:
Asian	Yes
Black or African American	If American Indian:
Native Hawaiian/ Other Pacific Islander	Tribe:
White/Caucasian

Mother’s Name:

Deceased

Mother’s DOB

Birth mother

Stepmother

Adoptive mother

Legal Guardian

Address

Home Phone

Town

State

Zip

Cell Phone

Place of Work:

Work Phone

Father’s Name

Deceased

Father’s DOB

Birth Father

Stepfather

Adoptive father

Legal Guardian

Address

Home Phone

Town

State

Zip

Cell Phone

Place of Work:

Work Phone

ABSENT PARENT:

Name:

Home Phone

Father

Mother

DOB

Cell Phone

Last Known Address:

Work Phone

Place of Work

Date of Last Contact

DJJS INVOLVEMENT

Yes

Worker’s Name

Telephone #

White - Placement Provider

Yellow - Case File

Additional Adults in household		Relationship
(Add additional names to the back of page)

Names of Siblings (in or out of the home)/Non-Sibling Minors			If other	DOB
(in the home) (Add additional names to the back of page)			checked,
			please
			specify
	Sibling	Other
	Sibling	Other
	Sibling	Other
	Sibling	Other
	Sibling	Other
	Sibling	Other

In Household

Yes No

EDUCATION & SCHOOL

SAU#

Home Schooled

Current School:

Current Grade:

Last School Attended:

Last Grade Completed:

Current School Telephone

Receive Special Education

Yes

504 Plan

Yes

Latest IEP Date:

Educational Coding

Educational Surrogate

Surrogate’s phone #

Have friends at school?

Yes

Know how to read?

Yes

Like the teachers?

Yes

Know how to write:

Yes

Like school?

Yes

Sports/School activities?

Yes

Resist going to school?

Yes

School	Behaviorally	Poor	Fair	Good		Great	Excellent
Performance	Academically	Poor	Fair	Good		Great	Excellent
Has youth ever been expelled or suspended?			Yes	No	If “yes”, explain

EMPLOYMENT OR VOLUNTEER WORK.
Currently Employed	Yes	No	If Yes: Employer Name:
Address					Work Phone number:
Average Hours Worked Per Week:				Interested in getting a job?			Yes	No
Perform community service or volunteer work?				Yes	No	If Yes please describe:

White - Placement Provider

Yellow - Case File

BIRTH FAMILY HISTORY (check all that apply)
Please specify type next to: **	Mother	Father

Allergies** Cancer** Mental Illness** Substance Abuse** Epilepsy (other seizure disorder)** Neurological Disorder** Tuberculosis Diabetes Suicidal Kidney Disease Heart Disease Others** Comments:

PHYSICAL & MENTAL HEALTH

Name of Youth’s Primary Care Physician

Last Physical Exam

Address:

Office Phone

Insurance Carrier:

ID No.

Medicaid No.

Allergies to medication (specify):

Allergies to food (specify):

Other Allergies (specify):

Current Medications:

Prescribed by:

Taken:

Both

In School

Taken:

Both

In School

Taken:

Both

In School

Taken:

Both

In School

Taken:

Both

In School

Taken:

Both

In School

Name of Therapist /Psychiatrist

Address

Office Phone

Frequency of visits:

Last session

Name of Dentist:

Last Dental Exam:

Address

Office Phone

Does youth wear eyeglasses?

Yes

Contact lenses?

Yes

Name of Eye Doctor:

Last Vision Exam:

Other Physicians:

Medical and Psychiatric Hospitalizations (dates & locations)

White - Placement Provider

Yellow - Case File

Diagnosed Medical and Psychiatric Conditions:

Tobacco Use:

Yes

Prior or Current Drug Treatment

Yes

If YES, where

and when

Drug Use:

Yes

If yes:

Marijuana

LSD

Opiates

Steroids

Amphetamines

Cocaine

Ecstasy

Methamphetamine

Benzodiazepines

Non-Prescribed Prescription Drugs

Other

Alcohol Use

Yes

SPEECH, HEARING & LANGUAGE.

Primary language spoken in the home:

Speaks more than one Language?

Yes

Speech impairment?

Yes

Hearing impairment?

Yes

American Sign Language

Reads

Signs

Interpreter Needed?

Yes

If yes, what language?

CHILDHOOD DISEASE HISTORY (Check all that apply)

Bronchitis	Chicken Pox	Ear Infections
German Measles	Heart Disease	Measles
Pneumonia	Tuberculosis	Other (please specify)
Immunization History Received		Yes	No

Epilepsy or other seizure disorder Mumps

DIET & NUTRITION FOR YOUTH.
Diagnosed eating disorders?	Yes	No	Require a special diet?	Yes	No
If Yes to either question please specify:

SLEEPING PATTERN:
Usual Bedtime				Usual wake time
Please describe sleeping pattern

Any diagnosed sleep disorders			Yes	No
If yes, please explain
Bed Wetting	Yes	No		Nightmares	Yes	No

White - Placement Provider

Yellow - Case File

STRENGTHS AND RESOURCES.

Often

Sometimes

Never

Often

Sometimes

Never

Benefits from structure Creative

Good self-control Positive manners Responds to direction Skill or interest in art Skill or interest in music Comments:

Club or group involvement Engaging personality Healthy self-esteem Positive adult relationships Positive peer relations Sense of humor

Skill or interest in athletics

OBSERVED BEHAVIORS. Identify the youth’s behaviors that may result in harm or injury to self or others:

Often

Sometimes

Never

Often

Sometimes

Never

Aggressive

Destructive

Tantrums

Poor Self-Esteem Sadness or Crying Sexual Acting Out Suicide Threats Suicide Attempts Self-Injurious

Details and Comments:

Assaultive

Cruel to Animals

Difficulty Concentrating

Fire setting

Lying

Stealing

Parentified

Running Away

Other:

RECREATION & LEISURE.

Does youth have a boyfriend or girlfriend? (Romantic involvement)				Yes	No
Does youth participate in structured community or school extracurricular activities or events				Yes	No
Details:

Is youth involved in a gang or cult?	Yes	No	Describe:

What does youth do for recreation or hobbies?

White - Placement Provider

Yellow - Case File

IMPORTANT PEOPLE IN THE YOUTH’S LIFE (CONNECTIONS)
Name	Address	Telephone	Relationship
		Number

This information is authorized to be shared with community based service providers, residential placement providers for the purposes of case planning and in order to maintain safety, permanency and well-being.


Signature of Parent/Guardian				Date
Signature of CPSW				Date
Name & Address of CPSW
Signature of Placement Provider				Date
Name & Address of Placement Provider
Signature of Foster Care Provider				Date
Name & Address of Foster Care Provider
Form Completed by:				Date

This section to be completed by the CPSW

The GAL/Casa assigned to the youth

Telephone Number

PD 10-26

White - Placement Provider

Yellow - Case File

STATE OF NEW HAMPSHIRE	Form 2281(i)
Department of Health and Human Services	October, 2010
Division for Children, Youth and Families

Instructions for the Youth Information Sheet (Form 2281)

PURPOSE;

The Youth Information Sheet provides essential information about the youth to the youth’s family and providers who have responsibility for the youth’s care.

INSTRUCTIONS:

The “Youth Information Sheet” is a 6-page form initially completed by the CPSW with the assistance of the youth’s parent or guardian for youth 14 years old or older. The Youth Information Sheet may be updated from the Child’s Information Sheet (Form 2267) for youth who were in foster care younger than 14 years of age. The Youth Information Sheet must be updated when a youth in placement turns 14 or is 14 or older at the time of placement and when changes occur in the youth’s placement, education, employment, medical, behavioral health or other significant event in the youth’s life. The Youth Information Sheet is provided to the parents, foster parent and residential facility when the youth is: initially placed in foster care, or changes placement, or returns home.

The “Youth Information Sheet” must be updated every 6 months while the youth remains in placement.

The current substitute care provider retains the original “Youth Information Sheet”. A copy must be retained in the case file. The youth’s subsequent care provider must be provided with the latest version of the “Youth Information Sheet”.

FORM COMPLETION:

By signing the form, the substitute care provider or parent of the returning youth acknowledges receipt of the document.

Enter as much accurate and detailed information that identifies the youth and provides essential details about his or her physical and behavioral health, school, habits and personality. Detail specific behaviors of the youth important for the current or future caregiver to know about, such as education needs, volunteer or employment interests, running away, suicide threats or attempts, and sleepwalking and other significant behaviors or needs of the youth.

1)Enter “NA” to indicate any information that is “not available” or “not applicable”.

2)Under Observed Behaviors add specific comments about behavioral health issues.

3)Sign and enter the name of the CPSW and location of the CPSW’s office.

4)Obtain the signature of the parent, foster parent or residential care provider.

RETENTION:

The “Youth Information Sheet” is retained in the case file.

PD 10-26

Question	Answer
Form Name	Form 2281
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	E-Mail, 2010, DJJS, blank information template

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