DCF-2102	State of Connecticut

08/2013 (Rev.)	Department of Children and Families	Page 1 of 2

DISCHARGE PLAN FOR CHILD WITH COMPLEX MEDICAL NEEDS

Child’s Name	Link Number	Date of Birth
Diagnosis
Foster Parent Name	Telephone
Address
DCF Social Worker	Telephone
DCF Area Office
Primary Health Care Provider	Telephone
Medical Needs and Equipment
Continuous O2	Apnea Monitor	Wheelchair
Intermittent O2	Sidelyer	Stander
Tracheostomy Care	Suctioning	Nasogastric Tube
Ventilator	Length of Time:	Nebulizer	Gastrostomy Tube
Continuous Positive Airway Pressure	Length of Time:	Other:
ALLERGIES (List):
Current Medications:
Prescription/Non-Prescription:	Dosage	Frequency
Immunizations: (During Hospitalization)
Special Diet:

Discharge Plan	Page 2 of 2, DCF-2102

Child's Name

Educational Needs:
At-home services:
Service	Frequency	Location
Out-of-home services:
Service	Frequency	Who Provides Transportation	Location

Therapy Needs:	Frequency	Location
PT
OT
Speech
Other:

Developmental Delay:
Yes	No
If yes, explain:

Physical Environment:
Handicapped Access:
Bathroom	Hallways	Outside ramp	Vehicle/wheelchair accessible	Generator
Other: (specify)

Home Care Services:
Agency:	Telephone:
Services Ordered:

FOLLOW-UP APPOINTMENTS:
Health Care Provide Name	Specialty	Telephone	Appointment Date

ADDITIONAL COMMENTS:

SIGNATURES:

Person Completing this Form:	Title:	Date:
DCF Social Worker:	Date:
Reviewed by RRG Nurse:	Date:
Approved by Area Office Behavioral Health PD:	Date: