Arrow Foster Parent Therapeutic Note

Date:
Foster child:
Foster parent(s):
Appointments scheduled this week:

Medical/Health concerns:
Provider name: Type of visit:
Medication changes? Prescription needed? Yes No N/A

Recreation
Sports event Cultural or spiritual activity
Dinner Party (what type? with whom?)
Movie Social activity with friends
Community event Social activity with family
Other (please list):

Visitation Yes No
With whom: Date(s):

Relationship(s)
:
Notable information regarding visit:

Education
Scheduled meeting Field trip Special occasion
Unscheduled meeting Academic support School refusal
Suspension Absence due to illness Absence due to appointment
Expulsion Other
Change in school placement
Additional information (date of meeting/absence/description of behaviors, etc) :

Employment
Does your child have a job? Yes No Full time Part time
Scheduled hours :

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 Attendance: poor good excellent
Job performance: poor good excellent
Any changes to hours, job responsibilities, type of employment, place of employment?

Behavioral
AWOL Property destruction Threatening Refusal
Physical aggression towards peer Self-injury Stealing
Physical aggression towards adult Substance abuse Tantruming
Oppositional Extreme disrespect Bullying Sexually acting out
Other:
Please provide additional information if behaviors have been noted:

AFS notified Emergency on call Police involvement Hospital

needed

Behavioral Resolution A reminder to use an IDEAL approach when dealing with challenging behaviors
Offered alternatives Gave chance to self-correct Thought it over place Coached to re-do correctly
IDEAL Immediate Direct Efficient Action based Level response to behavior
Other:

Positive Behaviors
Completed chores Used appropriate coping skills School/Work attendance
Positive behaviors in school Improved/Good grades Remained safe
Positive behaviors in the Respectful Followed directions
community
Demonstrated responsibility Appropriate boundaries Trustworthy
Other:

Other Information:

Foster Parent Signature Date

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AFS Signature Date

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