Adoption Assistance Amendment Request Confirmation of Needs

DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence

Subsidized Guardianship Amendment Request – Confirmation of Needs Emotional Characteristics (Ages Birth to 5)

Instructions: This form is to be used to confirm the special care needs of the child identified below and is to be completed by an appropriate professional (e.g., physician, therapist, school personnel, etc). Check the appropriate box in each category that most closely reflects the child’s current functioning and/or needs. If the child’s needs or functioning are age appropriate, the first box should be checked. Sign, date and provide your professional relationship to the child. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

Name – Child Birthdate (mm/dd/yyyy)

Name – Person Completing Form (Print) Professional relationship to Child Affiliation (e.g. school / medical facility, etc.)

SIGNATURE – Person Completing Form Telephone Number Date Signed

Check ONE box in each category that best describes the child’s current functioning / needs. If the child’s needs or functioning are age appropriate, the first box should be checked.

Adjustment / Emotional Response to Past Trauma – Affect Regulation (PAST 30 DAYS) Infant / child has no Infant / child has mild to Infant / child has significant Infant / child has severe problems with emotional moderate problems with problems with emotional problems regulating affect / response. Concerns are emotional response response regulation but is emotional response even age / developmentally regulation. able to control affect at with caregiver’s support. appropriate or this times. Problems are information is unknown to interfering with child’s me. functioning. If the child’s needs / functioning fall within a shaded box, explain why:

Adjustment to Past Trauma – Re-experiencing the Trauma (PAST 30 DAYS) There is no evidence that Child experienced some Child experiences Child experiences repeated infant / child re-experiences indications that the trauma consistent indications that and severe incidents of re- the trauma. Concerns are was being re-experienced the trauma is being re- experiencing trauma that age / developmentally in the form of sleep experienced: sleep significantly interferes with appropriate or this disruption or play after the disturbance, nightmares. functioning and can not be information is unknown to trauma but is no longer Play mimicking trauma managed by caregivers. me. present. Subtle changes in experienced. child’s functioning. If the child’s needs / functioning fall within a shaded box, explain why:

EMOTIONAL CHARACTERISTICS (Ages Birth to 5)

Adjustment to Past Trauma – Avoidance (PAST 30 DAYS) No evidence of avoidant Mild problems with avoiding Moderate problems with Severe problems with behavior. Concerns are some situations either after avoidant behavior that avoidant behavior that age / developmentally the trauma or presently on occurs on a consistent occurs consistently but appropriate or this an infrequent basis. Infants basis when child is cannot be mediated by information is unknown to due to limited mobility rarely exposed to triggers related caregivers and causes me. exhibit this symptom. to the trauma. Caregiver significant distress. can support the child. If the child’s needs / functioning fall within a shaded box, explain why:

DCF-F-2869-E (N. 01/2013) Adjustment to Past Trauma – Increased Arousal (PAST 30 DAYS) No evidence of increased Infant / child may have a Infant / child demonstrates Severe problems with arousal. Concerns are age history of increased arousal increased arousal most of attachment. A child who is or developmentally or currently shows this the time. Infants appear unable to separate or a appropriate or this behavior on an infrequent wide eyed, over reactive to child who appears to have information is unknown to basis. stimuli, and have severe problems with me. exaggerated startle forming or maintaining response. Older children relationships with may have all of the above caregivers. with behavioral reactions such as tantrums. If the child’s needs / functioning fall within a shaded box, explain why:

Adjustment to Past Trauma – Numbing Response (PAST 30 DAYS) No evidence of numbing Child exhibits some Child has moderate Child has significant response. Concerns are problems with numbing. difficulties with numbing numbing responses or age or developmentally Child may have a restricted responses. Child may have multiple symptoms of appropriate or this range of affect or an blunted or flat emotional numbing. Diminished information is unknown to inability to express or state or have difficulty interest or participation in me. experience certain experiencing intense activities. emotions (e.g., anger or emotion or feel consistently sadness). detached or estranged from others. If the child’s needs / functioning fall within a shaded box, explain why:

Regulatory (PAST 30 DAYS) Child has no evidence of Some problems with Moderate problems with Profound problems with regulatory problems regulation. Infants may regulation. Children may regulation are present that including ability to control have unpredictable patterns have severe reactions to place the child’s safety, well bodily functions such as and be difficult to console. stimuli and emotions that being and / or development eating, sleeping, Older children may require interfere with their at risk. eliminating, sensitivity to a great deal of structure functioning and ability to external stimulation, etc. or and need more support progress developmentally. this information is unknown than other children in Unpredictable patterns in to me. coping with frustration and eating and sleeping difficult emotions. routines that disrupt the rest of the family. If the child’s needs / functioning fall within a shaded box, explain why:

Eating (PAST 30 DAYS) No evidence of problems Mild problems with eating Moderate problems with Severe problems with relating to eating. that have been present in eating are present and eating are present putting Concerns are age or the past or are currently impair the child’s the infant / child at risk developmentally present some of the time functioning. Children may developmentally. The child appropriate or this causing mild impairment in seriously overeat, refuse and family are very information is unknown to functioning. most foods and not have a distressed and unable to me. clear pattern of when they overcome problems in this eat. area. If the child’s needs / functioning fall within a shaded box, explain why:

2 Elimination / Bathrooming (PAST 30 DAYS) There is no evidence of Infant / child may have a Infant / child demonstrates Infant / child demonstrates elimination problems. Any history of elimination problems with elimination significant difficulty with concerns are age or difficulties but is presently on a consistent basis that is elimination to the extent developmentally not experiencing this other interfering with the child’s that child / parent are in appropriate or this than on rare occasions. functioning. (Lack of significant distress or information is unknown to routine resulting in interventions have failed. me. (This does not include constipation, encropsesis potty training concerns.) and enuresis.)

If the child’s needs / functioning fall within a shaded box, explain why:

Sensory Reactivity (PAST 30 DAYS) There is not evidence of Infant / child may have a Infant / child demonstrates Infant / child demonstrates sensory reactivity that is history of sensory issues or under / over reactivity to significant reactions to under or over reactive. Any mild issues currently that sensory input in one or sensory input so that the concerns are age or are controlled by caregiver more area which impairs caregiver is unable to help developmentally support. the child’s functioning. the child. appropriate or this information is unknown to me. If the child’s needs / functioning fall within a shaded box, explain why:

Emotional Control (PAST 30 DAYS) Infant / child has no Infant / child has mild Child has a moderate level Infant / child has significant problem with emotional problems with emotional of problems with emotional level of emotional control control. Any concerns are control that can be control that interferes most problems that are age or developmentally overcome with caregiver of the time with functioning interfering with appropriate or this support. (difficult to console, does development. Caregivers information is unknown to not respond to caregiver are not able to help the me. support, becomes child. physically aggressive out of frustration). If the child’s needs / functioning fall within a shaded box, explain why:

Sleep – Child Must be 12 Months or Older (PAST 30 DAYS) Child gets a full night’s Child has some problems Child is having problems Child is experiencing sleep each night. Any sleeping. Toddlers resist with sleep that might significant sleep problems concerns are age or sleep and consistently need include difficulty falling that result in sleep developmentally a great deal of adult asleep, night waking, night deprivation that affects the appropriate or this support to sleep. terrors or nightmares on a child’s functioning. Parents information is unknown to Preschoolers may have a regular basis (4 or more have exhausted numerous me. history of poor sleep or times per week). strategies for assisting continued problems 1-2 child. nights per week. If the child’s needs / functioning fall within a shaded box, explain why:

Attachment (PAST 30 DAYS) No evidence of problems Mild problems with Moderate problems with Severe attachment with attachment. Any attachment. Children may attachment and may fail to problems. Children concerns are age or be overly reactive to demonstrate stranger attachment to anyone or no developmentally separation or seem anxiety or have extreme one in an extreme manner. appropriate or this preoccupied with parent. reactions to separation Child meets criteria for information is unknown to Boundaries may seem resulting affecting Reactive Attachment me. inappropriate. development, may avoid Disorder. caregivers and have inappropriate boundaries putting them at risk. If the child’s needs / functioning fall within a shaded box, explain why:

Depression (PAST 30 DAYS) No evidence or concern Child may be depressed or Moderate problems with Clear evidence of a about depression. Any has experienced situations depression are present. disabling level of concerns are age or that may lead to Children may have depression that makes it developmentally depression. Infants may negative verbalizations, no virtually impossible for the appropriate or this appear withdrawn and slow emotional response, dark / child to function in any life information is unknown to to engage at times. Older sad play and demonstrate domain. me. children are irritable or do little enjoyment in play and not demonstrate a range of interactions. emotional response / affect. If the child’s needs / functioning fall within a shaded box, explain why:

Anxiety (PAST 30 DAYS) No evidence or concern History or suspicion of Anxiety with significant Clear evidence of about anxiety. Any anxiety problems or mild to fearfulness that has debilitating level of anxiety concerns are age or moderate anxiety. Infant / interfered significantly in that makes it virtually developmentally child may appear anxious child’s ability to function. impossible for the child to appropriate or this in certain situation but has Child may be irritable, over function in any area of life. information is unknown to the ability to be soothed / reactive to stimuli, me. calmed. uncontrollable crying and significant separation anxiety. If the child’s needs / functioning fall within a shaded box, explain why:

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