CHILD/YOUTH MATCHING PROFILE

child’s first name or pseudonym:	birth month and year:
age in years:

case manager’s name	district office	phone number
case manager e-mail
send home studies to:	Name of Resource Worker	date home study due:
resource worker e-mail:

date of matching meeting:	time:	location:
date of this profile being completed:
what type(s) of homes are you willing to consider? (Check all that apply)
iso foster home (if checked, the field administrator has approved iso foster care, please also explain need for iso)
general foster home
general foster home with in home supports (explain):
respite home
bridge home
adoptive home

preferred placement location:
primary language:
spirituality: (beliefs, religious preference)
ethnicity (check all that apply)
american indian/alaskan native	hispanic origin yes no unknown
asian
black or african american	if american indian:
native hawaiian/ other pacific islander	tribe:
white

reason for dcyf involvement:
physical abuse	sexual abuse	educational neglect
neglect	medical neglect	psychological/emotional abuse

jjs involvement:	yes	no
length of time in care:	number of placements:
permanency goal:	concurrent goal:
reunification	guardianship	reunification	guardianship
adoption	appla	adoption	appla
is the child legally free for adoption:	yes	no
if yes, what recruitment efforts have been used? (recruitment efforts, i.e., waiting children, heart gallery, adoptuskids)

current placement:
foster home	location:
iso foster home	location:
residential care:	specify:
relative placement:	location:
personality, interests and hobbies: including strengths of the youth and career goals
behavioral issues that have impacted placement stability (e.g. attachment difficulty, lying, destruction of property, stealing etc)
medical conditions/ mental health issues (check all that apply)
qualify for dd waiver or adult services
neurological issues
health problems (such as asthma, hep. c)
enuresis
encopresis
obesity or history of malnutrition
history of malnutrition
eating disorders
learning disabilities due to emotional issues
fetal alcohol spectrum disorder or diagnosis of fae/fas
mental health diagnosis: please specify:
other (please explain)

educational status
does the child/youth work at grade level?	yes	no
does the child/youth have an iep?	yes	no
if yes; what is their ed. id/coding?
legally liable school district:

sibling placement or ongoing sibling contact:
does the child or youth have siblings?	yes	no
is the intention to place them together?	yes	no
if no, is the intention to have them maintain contact?	yes	no
if no, explain:

connections to be maintained after placement (please note if there will be future changes to this contact):
first name	relationship	type of contact	frequency	location of visit

youth’s desires/ preference for a family:
birth family, placement provider and casa recommendations for a family:

foster or adoptive family skills and characteristics that might be preferred for this youth: (family composition, location, pets in the home, ability to manage specific behaviors etc)
work needed with family (birth, relative, pre-adoptive)
reason for needing a new family/placement:

other information:

please attach the child’s current picture!