WPC  8#2 yxKha 4jdAۛy/ ^w cX *~X LV ,n"XV XU2k\ ʃ*PY+Om|0#u AFB!*#zl;?s>cRs=emib7P*ECh;QM~])̤o 6_q%0a~w<8wez9YH.8U!i= |Bd "q)& v)7uJ@,k%60I4H}Yz`K8HP|A5{6PsdgY|uO{ci]U֑)2khDE{ylm,>R{g^D 'k^,>n>.ۅ7+jdE~ GF&U>B 0n  0<z 0#`UN) %w M} ( N 1 722 1ud 72 0c ^ n wz 4~  m \  `&Times New Roman'  dalvey0rbowman .   <:Default ParaXXX<:Footnote Ref#|x(r$..      XXXXXXXXHP LaserJet 4100 Series PCL,,,,0&d9 Z6Times New Roman RegularX(CEKQW]cioAutoList11)1)1)1)1)1)1)1) 1)3#37=CIQYag1.a.i.(1)(a)(i)1)a)i)(;3$2#  0  .3  0  &4 54:i+00U !..      X5XXXX5XXX5  _ X9       wJswXX5 ,X   @  @  @4  @`  @  @  @  @  @<  @h  @  @  @  @  @D  @p  @  @  @  @  wwJsCFS2004Instructions X Rev.July2006  Pg.1of1 t :0p x (#,0QII$I$$N$> X5X>  INSTRUCTIONSFORNEEDSASSESSMENT#>XX5M# T lH9H.` hp x (#X(#HӀFORTHERAPEUTICFOSTERCAREANDLEVELVRESIDENTIALTREATMENT )  (83"3"  &%>32  1  )3  0 e   ThisisusedforyouthwitharecommendationfordTherapeuticFosterCare(_TFC_)orLevelVResidential O  Treatment. .ItisNOTusedforyouthdirectlycommittedtoacorrectionalfacility(wedonothaveaplacement    decisiontomakewiththoseyouth).ThisisalsousedforserviceextensionsforTherapeuticFosterCare,but    notforLevelV.LevelVserviceextensionsareauthorizedthroughascreencompletedbytheCommunity  C  MentalHealthCenterclosesttotheLevelVfacility. 3^݌_  e$e$ Ќ  d 2) 0 e TheMedicaidnumberneedstobeincludedonall extensionassessments.Forinitialassessments, pending   maybeusedinitially,tobereplacedbythenumberwhenitbecomesavailable. S e$e$  3) 0 e TheLevelofCareiswheretheyouthisattimeofassessment. Forextensionof_TFC_Ԁservices,itMUSTbea 3   TherapeuticFosterHome.  e$e$  4) 0 e TheCommunityCaseManagementAgencyistheagencyresponsiblefortheyouthbyJudicialDistrict.(_ie_:in ' SedgwickCountyitisSedgwickCountyDepartmentofCorrections_SCDOC_).Ce$e$  5) 󀀀0 e TheCaseManager/socialworker,istheindividualrepresentingthe_CCMA_Ԁ/_CWCBS_ԀProvider/_SRS_Ԁoffice s assignedtothisyouthscase.7e$e$  6) 0 e AllquestionsaretobeansweredandaretohavethehighestrankingappropriateanswerCIRCLED.Forinitial  assessments,ALLquestionsaretobeanswered.For _TFC_Ԁserviceextensionassessments,onlythebottomgroup  ofquestionsisanswered.Ge$e$  7) 󀀀0 e Forinitialassessments,thescoringboxatthebottomleftoftheformisusedtofindrecommendedplacement. 'e$e$  8) 󀀀0 e Theassignedcasemanager/workerwillcompletetheinitialassessment,thengiveittotheir_CCMA_Ԁ/ W! _CWCBS_/_SRS_ԀauthorizedstaffforsignatureontheSupervisoryApprovalline.Oncecompletedandsigned,this s" documentshallalsobegiventothe_TFC_ԀorLevelVprovider.Theserviceprovidercanusethisformto 7# developtheirplanofcare. Theserviceprovidersendsthisformdalongwiththe_YA_Ԁ2833andthePrior $ Authorizationformfoundin_KMAP_ԀtoEDStoauthorizepayment.g%e$e$ d 9 󀀀ForextensionofTFCservices,theTFCserviceproviderwillhaveanappropriatestafffromtheirprogram G' Ѐcompletetheassessmentforserviceextension.Ifthescoringindicatesajustificationforextension,theTFC  ( Ѐproviderwillthenfaxormailtheassessmenttotheyouthscasemanager.dIfthereisagreementthechild  w) ЀshouldcontinuetoreceiveTFCservices,thecasemanagerwillthenberesponsibleforgettinganauthorized !;*  Xsignatureonthesupervisoryapprovalline,and faxingormailingthesignedformbacktotheTFCprovider. W"+ TheTFCproviderwillthenberesponsibleforgettingtheformtoEDS,alongwithanewYA2833andPrior # , Authorizationformtoauthorizepaymentfortheextension. Thissameprocesswillbecompletedeachtime #!- thereisneedtoreassessforanextensionofTFCservices. % d