Refuge House Forms Library

Review Period Information

Review Period From

Review Period To

Review Due Date

Reviewer Name

Reviewer Title

Review Type

Quarterly

Annual

Special Review

Number of Children Currently Placed

Service Packages Home is Credentialed For

Placement Summary

All placements during review period

Child Name	Service Package	Placement Date	Discharge Date	Stability	Incidents
Child A	Mental & Behavioral Health	2024-09-15	Current	Stable	0
Child B	T3C Basic	2024-11-01	Current	Stable	1

Total Placements This Quarter

2

Successful Discharges

0

Unplanned Disruptions

0

Average Length of Stay

45 days

Training Compliance Dashboard

Core Requirements

TBRI® Certification

Expires: 2025-06-15

40 hours completed

Current

CPR/First Aid

Expires: 2025-03-20

Current

Medication Administration

Expires: 2025-01-30

Expiring

Emergency Behavior Intervention

Expires: 2025-08-10

Current

Annual Training Progress

Required Hours: 30Completed: 22

Topics Completed:

TBRI Refresher

Trauma-Informed Care

Crisis Management

Mental & Behavioral Health Training

Mental Health First Aid

Date: 2024-08-15

Current

Crisis Prevention (CPI)

Date: 2024-09-20

Current

Trauma-Focused Interventions

Date: 2024-07-10

Current

T3C Credentialing Assessment (FC-CRED-01 Integration)

TBRI® Implementation Evaluation

Rate each area 1-5 with evidence notes

Connecting Principles

Building trust and attachment

Empowering Principles

Meeting physical and emotional needs

Correcting Principles

Addressing behavioral challenges with compassion

Overall TBRI® Fidelity Rating

Service Delivery Capabilities

Maintains safe therapeutic environment

Implements treatment plans effectively

Maintains required documentation

Collaborates with treatment team

Supports normalcy activities

Available 24/7 for emergencies

Mental & Behavioral Health Competencies

Crisis Management Skills

Ability to de-escalate and manage crisis situations

De-escalation Effectiveness

Success in preventing escalation of behaviors

Therapeutic Boundaries

Maintains appropriate professional boundaries

Home Environment & Safety

Quality Indicators

Strengths Observed This Quarter

Areas for Growth

Support Provided by Agency

Foster Parent Feedback

Satisfaction with agency support (1-5 scale)

Biggest challenges this quarter

Additional support needed

Credentialing Determination

Children-Specific Summaries

Child: Child A

Placement Stability

Foster Parent Engagement

TBRI Implementation

Specific Successes

Support Needs

Child: Child B

Placement Stability

Foster Parent Engagement

TBRI Implementation

Specific Successes

Support Needs

Compliance & Sign-offs

Documentation Review

All incident reports filed appropriately

Medical logs current

Service documentation complete

Financial records in order

Signatures

Foster Parent(s)

Date

Home Developer

Date

Program Director

Date

Distribution

Copy to foster home file

Update credentialing status in Radius

Flag any children affected by credential changes

Schedule follow-up if improvements needed

Quarterly Foster Home Review & Credentialing Assessment

Core Requirements

Annual Training Progress

Mental & Behavioral Health Training

TBRI® Implementation Evaluation

Service Delivery Capabilities

Mental & Behavioral Health Competencies

Physical Environment

Recent Changes

Support Provided by Agency

Foster Parent Feedback

Current Credentials Maintained

Add-On Services

Recommendation

Child: Child A

Child: Child B

Documentation Review

Signatures

Distribution