Cso1079c 2026

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141 votes

The document is a Child Certification Documentation Attachment for the Arizona Department of Child Safety's Adoption Subsidy Program. It requires completion by a child's medical, dental, or behavioral health professional to assess eligibility for the subsidy and document any pre-existing conditions. The form collects information on the child's diagnoses, severity, current treatment, prognosis, and potential risks for disabilities or emotional disturbances.

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Click ‘Get Form’ to open the cso1079c in the editor.
Begin by entering the child's name in the designated field, followed by their date of birth. This information is crucial for identifying the child.
For each diagnosis, input the diagnostic code and description. You will find fields for up to four diagnoses; ensure you provide accurate details for each.
Indicate the severity of each diagnosis using a scale from 1 (mild) to 5 (extremely severe). This helps assess the child's needs effectively.
In the 'Current Treatment and Prognosis' section, describe any ongoing treatments and expected outcomes for each diagnosis.
Answer whether the child is at risk of developing any disabilities or emotional disturbances by selecting 'YES' or 'NO', and provide an explanation if applicable.
Finally, fill in your professional details including name, degree, specialty, address, phone number, and sign where indicated.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (141 Votes)

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