DCYF Form 15-209A "Health/Mental Health and Education Summary" - Washington

What Is DCYF Form 15-209A?

This is a legal form that was released by the Washington State Department of Children, Youth, and Families - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2019;
  • The latest edition provided by the Washington State Department of Children, Youth, and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DCYF Form 15-209A by clicking the link below or browse more documents and templates provided by the Washington State Department of Children, Youth, and Families.

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Download DCYF Form 15-209A "Health/Mental Health and Education Summary" - Washington

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ATTENTION: This is an electronic form in FamLink. This Word version must only be used when FamLink is not available.
STATE OF WASHINGTON
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Health / Mental Health and Education Summary
Date:
To:
From:
Phone:
Email:
Attached, please find a comprehensive health report for the following child:
NAME OF CHILD
DATE OF BIRTH
If this child is no longer living with you, please destroy this document as you would any confidential information or return it
to your social worker.
The information contained in this report is confidential, however, it should be shared with the child’s physicians,
dentists and therapists to assure appropriate services are provided.
The information included in this report is limited by the availability of health and education records. This report is
supplemental to any previous health reports created. All medications listed in this report should be discussed with the
child’s primary health care provider. Please take this report with you to all health/mental health appointments.
If I may be is assistance, or if you have any questions, please do not hesitate to call me. Also, please contact me at any
time with new health and education concerns you might have for this child.
Thank you for your time.
NOTE: The information displayed is not a complete or current reflection of the child’s health care status. Please
consult with the child’s medical providers before using this information to guide physical or behavioral health
care for a child. All information contained in this report is confidential, and disclosed under the limitations of RCW
13.50.100. This disclosure does not constitute a waiver of any confidentiality privilege attached to the records by
operation of any state or federal law or regulation. The recipient of these records must comply with the laws governing
confidentiality and must protect the records from unauthorized disclosure. The recipient should share this information with
the child’s health care provider
HEALTH / MENTAL HEALTH AND EDUCATION SUMMARY
DCYF 15-209A (02/2019) INT/EXT/FAMLINK
ATTENTION: This is an electronic form in FamLink. This Word version must only be used when FamLink is not available.
STATE OF WASHINGTON
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Health / Mental Health and Education Summary
Date:
To:
From:
Phone:
Email:
Attached, please find a comprehensive health report for the following child:
NAME OF CHILD
DATE OF BIRTH
If this child is no longer living with you, please destroy this document as you would any confidential information or return it
to your social worker.
The information contained in this report is confidential, however, it should be shared with the child’s physicians,
dentists and therapists to assure appropriate services are provided.
The information included in this report is limited by the availability of health and education records. This report is
supplemental to any previous health reports created. All medications listed in this report should be discussed with the
child’s primary health care provider. Please take this report with you to all health/mental health appointments.
If I may be is assistance, or if you have any questions, please do not hesitate to call me. Also, please contact me at any
time with new health and education concerns you might have for this child.
Thank you for your time.
NOTE: The information displayed is not a complete or current reflection of the child’s health care status. Please
consult with the child’s medical providers before using this information to guide physical or behavioral health
care for a child. All information contained in this report is confidential, and disclosed under the limitations of RCW
13.50.100. This disclosure does not constitute a waiver of any confidentiality privilege attached to the records by
operation of any state or federal law or regulation. The recipient of these records must comply with the laws governing
confidentiality and must protect the records from unauthorized disclosure. The recipient should share this information with
the child’s health care provider
HEALTH / MENTAL HEALTH AND EDUCATION SUMMARY
DCYF 15-209A (02/2019) INT/EXT/FAMLINK
ATTENTION: This is an electronic form in FamLink. This Word version must only be used when FamLink is not available.
DEPARTMENT OF CHILDREN, YOUTH, AND FAMILIES (DCYF)
Health / Mental Health and Education Summary
Child Information
CHILD’S NAME
GENDER
DATE
Male
F
l
DATE OF BIRTH
AGE
STATE STUDENT ID
PERSON ID
Health / Mental Health Conditions
DATE IDENTIFIED
END DATE
MEDICALLY CONFIRMED
CURRENT / HISTORICAL
CONDITION
SOURCE
PROVIDER NAME
PHONE NUMBER
COMMENTS
Exams / Evaluations
EXAM DATE
PROVIDER NAME
PHONE NUMBER
TYPE OF EXAM
EXAMS / PLANS / RECOMMENDATIONS
Allergies
DATE IDENTIFIED
END DATE
MEDICALLY CONFIRMED
CURRENT / HISTORICAL
ALLERGIC TO
ALLERGIC REACTION
ALLERGIC REACTION PLAN
Medications / Equipment
PRESCRIPTION DATE
MEDICATION OR EQUIPMENT NAME
DOSAGE
PROVIDER NAME
PHONE NUMBER
REMARKS
Hospitalizations
ADMIT DATE
DISCHARGE DATE
TYPE
ER / INPATIENT
HEALTH / MENTAL HEALTH AND EDUCATION SUMMARY
DCYF 15-209A (02/2019) INT/EXT/FAMLINK
ATTENTION: This is an electronic form in FamLink. This Word version must only be used when FamLink is not available.
HOSPITAL NAME
PHONE NUMBER
PROVIDER NAME
ADMIT / DISCHARGE INFORMATION
Mental Health Treatment
DATE
TREATMENT PLAN
PROVIDER NAME
PHONE NUMBER
COMMENTS
Appointments
APPOINTMENT DATE
APPOINTMENT TIME
TYPE
PROVIDER NAME
PHONE NUMBER
Birth Information
WEIGHT
HEIGHT
TOX SCREEN
GESTATIONAL AGE
APGAR
EXAMS / RECOMMENDATIONS
HOSPITAL NAME
PHONE NUMBER
PROVIDER NAME
Immunizations
DATE
IMMUNIZATION
SOURCE
School Information
ENROLLED DATE
END DATE
PRIMARY SCHOOL
SCHOOL NAME
DISTRICT
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
SCHOOL YEAR / TERM
CURRENT GRADE
CURRENT PERFORMANCE
Special Education
SPECIAL EDUCATION SERVICES NEEDED OR
SUPPORTING DETAIL
PROVIDED
Yes
No
TYPE
START DATE
REVIEW DATE
END DATE
IEP
504
IFSP
COMMENTS
Referrals
REFERRAL DATE
REFERRAL TO:
COMMENTS
HEALTH / MENTAL HEALTH AND EDUCATION SUMMARY
DCYF 15-209A (02/2019) INT/EXT/FAMLINK
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