Final Report--Integrated Information System for Foster Care and Adoption

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Final Report--Integrated Information System for Foster Care and Adoption

Final Report --- Integrated Information System for Foster Care and Adoption

Health and Human Services

Lutheran Child and Family Services

July 21, 1997

Submitted by Daphna Oyserman in conjunction with David Van Eck

University of Michigan

INTRODUCTION

This document provides an overview of the progress made in development of a tool to integrate foster care and adoption information documentation as well as development of a tool to track foster family licensing and training. Funding for this development came to the Merrill-Palmer Institute, Wayne State University from Health and Human Services grant # 90-PD-0200 as well as from Lutheran Child and Family Service of Michigan (funding from the McGregor Foundation). This report is accompanied by the full software application including the foster care information system developed with the initial Health and Human Services funding.

REVIEW OF GOALS

We obtained an additional year of Health and Human Services funding to develop a link between foster care and adoption information collection and documentation. We also obtained funding from Lutheran Child and Family Service of Michigan to develop a foster families licensing and training module. The need for this development was highlighted by two basic realities: First, a substantial number of children who enter foster care are eventually freed for adoption and are often adopted by their foster parents. Second, information about the child’s early experiences and family of origin that is needed for the adoption process is often only accessible in the initial period after removal from the home. Therefore, we proposed to both more fully develop the Foster Family Licensing and Training modules with the information needed for an Adoption home study kept in mind; as well as modify the previously developed Integrated Information System for Foster Care to contain information that would be needed for a Pre-Adoption Child Summary. This would allow us to develop an adoption module containing both Child Summary and Home Study modules which would allow information to flow from foster care where available as well as set up an orderly information documentation system and data base specifically for foster family licensing and child adoption.

OUTCOME SUMMARY:

Both the Foster Family Licensing and Training and the Adoption Child Summary and Home Study Modules are developed. We have printed all of the screens of these modules and attached them to this report. The modules contain a large number of discrete variables. The variables take the form of single and multiple-choice lists and open-ended information. Open-ended information is integrated with a word-processing tool including a spell check. All information contained in the variables is available for report generation. A description of the overall framework of the IIS is currently in press in the professional journal: Computers in Human Service Organizations. This article is also attached to this report. We found that the adoption module highlighted child psycho social and academic-cognitive development in ways that would be beneficial for the foster care progress reports. We also found that the foster family licensing component provided structure for the assessment of family functioning in the adoption home study. Information that is embedded in the Foster Child and Foster Family tools for the use of the Adoption Module is highlighted in summary form in the last section of this report.

The current foster care tools are running on a DOS platform. Future versions of the software will run on the new generation of database development tools. The current foster care information system contains open-format data that would need to be converted to list form to fully comply with adoption requirements. However, such a conversion of the open-format data to the more structured close-ended requirements of the adoption tools would require large scale re-writing of the foster care program. Since such an extensive revision is best conducted as part of a next stage effort for advancement of child welfare information tools, we decided to develop an interim summary report of the foster care experience for children entering adoption from a foster care agency using our Integrated Information System. This interim report will allow workers to take advantage of the information currently collected until a new generation of tools is developed. As described below, Rami Benbenishty is currently involved in developing the next generation of tools, however this effort is clearly beyond the scope of the current funding. Given the constraints of time and funding, it was deemed more appropriate to utilize the current grant to develop a tool that could be the basis for further development. The next generation of the software for use with adoption is being developed in conjunction with Spaulding for Children.

The current IIS software is installed at LCFS, with 4 additional planned installations -- Spaulding for Children, St. Francis Home, Evergreen Children’s Services and Catholic Social Services of Grand Rapids. Spectrum Human Services purchased the software three years ago. Approximately 100 front-line workers are using the software as part of their daily routine. None of the reports generated by the software have ever been returned with problems from the Family Independence Agency (formerly the Department of Social Services). Front-line staff particularly appreciates the fact that by answering all of the queries in the software, they are sure not to miss any reporting information. The current software is being serviced by Common Ground Computing, the company established by our programmer, David VanEck. In addition, a DOS version of the IIS was extensively customized to meet the licensing requirements of the Commonwealth of Pennsylvania and is currently being used by Episcopal Community Services of Philadelphia.

OTHER RELATED PROJECTS DEVELOPED AS A RESULT OF THE FOSTER CARE WORK:

As a result of the intensive work with foster care and exploration of issues related to entry into foster care as well as socio emotional and academic risks associated with foster care, two lines of research have been established, the first is focused on parenting issues for mothers with a serious mental illness and the second is focused on risk and resilience among high risk youth. The first line of research (Mothers with a Serious Mental Illness: Coping with Parenthood) is an NIMH funded project (Grant # R01 NIMH5432, Mowbray & Oyserman, Co-PIs). We have collected baseline data on 379 mothers with a chronic mental illness who are served through the public mental health system and have care responsibility for at least one child aged 4-16. We have currently obtained a competing renewal of the grant and are funded to follow these mothers for 3 additional years. This research interest was the result of finding that a substantial minority of children in the foster care system has mental illness in their background. The second line of research has been funded through a W.T. Grant Foundation research scholar award to Daphna Oyserman as well as funding through the Michigan Prevention Research Center. This research has resulted in two NIMH proposals. The first aims at following the children of the mentally ill mothers in our sample (Pathways for Youth: Risk and Resilience), while the second aims at testing a preventive intervention focused on for inner city and minority youth (School-to-Jobs). These projects though not directly focused on foster care, focus on the issues found to be relevant to the children in the foster care systems - high risk family systems as well as concern about the youth’s own psycho social and academic development.

FUTURE GOALS:

This project was established as a university-based initiative with a goal of providing tools for dissemination in public and private child welfare organizations. After the initial university-based development and dissemination efforts, it became clear that what was necessary was a more business oriented approach. Child welfare agencies made clear that they couldn't feel comfortable working with an academic partner after initial development phases are completed. Agencies require a contractual commitment to ongoing support and a maintenance commitment that can best be provided to them by commercial software vendors. To this end, a license agreement was entered into with Common Ground Computing. This agreement had a one-year benchmark for re-deployment of the IIS program under a Windows platform. This task went unmet due to Common Grounds’ contractual commitments to Wayne State University to work on development of the DOS-based IIS. Therefore the licensing agreement was discontinued. With regard to future development, Rami Benbenishty is continuing to work on development of the new generation of tools using a window platform. This is an entirely independent commercial effort. The goal of improving quality of care in child welfare services of course remains.

CHANGES IN THE FOSTER CARE SOFTWARE TO PROVIDE INFORMATION FLOW TO FOSTER FAMILY LICENSING AND ADOPTION (AND CHANGES IN THE FOSTER FAMILY LICENSING SOFTWARE TO PROVIDE INFORMATION FLOW TO ADOPTION):

Changes in the foster care program focused both on obtaining more specific information on the child and biological family needed for adoption and also on obtaining specific information needed to better track foster family licensing. Information needed for adoption involves obtaining both more specific information about the family of origin --their health, education, interests and hobbies; as well as documentation wherever possible. And also obtaining more extensive information about the child. An example of the latter included obtaining more specific medical and mental health information both at intake and over time. As well as obtaining more specific information about the child’s social, emotional, cognitive, and physical development and challenges at each assessment point while in foster care. This information enriched the perspective of the foster care worker on the child, reminding the worker that while children enter care due to problems that their parents are experiencing in providing an adequate and safe environment. An example of the latter included adding specific information about the challenges and issues faced by the foster child in each report period, an assessment of the outcomes and of the role of the foster parent and foster worker in attaining these outcomes.

APPENDIX 1

Screens of the Foster Family Licensing Component

The following are the major screens that make up the foster family licensing component. We have not shown the instructions with regard to single and multiple list choices or the open-ended text information. Screens are numbered and presented in order of presentation to the user. Users can move directly to screens of interest using the index, which has not been printed.

+ -X123456------Fos. Fam. # 1-----------+

¦ Foster Family Information ¦

¦ Family Name.......: ¦

¦ Family Number.....: X123456 ¦

¦ where learned about fostering: ¦

¦ Specify Source....: ¦

¦ Other.............: ¦

¦ Address...........: ¦

¦ City/State........: ¦

¦ Zip...............: ¦

¦ County............: ¦

¦ Directions to home: ¦

¦ Home Phone........: ¦

¦ Emergency Phone...: Name..: ¦

¦ First Work Phone..: Name..: ¦

¦ Second Work Phone.: Name..: ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ -X123456------Fos. Fam. # 2-----------+

¦ ¦

¦ Training ¦

¦ ¦

¦ To update training information you must go into the training area for ¦

¦ this family. The information here is for display only. ¦

¦ ¦

¦ Rule 203 ¦

¦ ¦

¦ Completed: ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦ Topic Date Location ¦ ¦

¦ ¦--------------------------------------------------------------------------¦ ¦

¦ ¦ ¦ / / ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦ ¦--------------------------------------------------------------------------¦ ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

+ -X123456------Fos. Fam. # 3-----------+

¦ ¦

¦ Rule 204 - Before providing a person with an application for licensure of a ¦

¦ foster home, an agency shall document that the person has ¦

¦ received all of the following: ¦

¦ ¦

¦ State whether this family has received each of the following and the ¦

¦ date it was received ¦

¦ ¦

¦ a.) A copy of the Act.........................................: ¦

¦ ¦

¦ b.) A copy of the licensing rules for foster homes............: ¦

¦ ¦

¦ c.) A copy of the licensing rules for child placing agencies..: ¦

¦ ¦

¦ d.) A copy of the agency's service policies governing foster ¦

¦ care as required pursuant to the provisions of R400.12304.: ¦

¦ ¦

¦ e.) A copy of the agency's foster parent training requirements: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -X123456------Fos. Fam. # 4-----------+

¦ Orientation Cont... Date Given Date Due Date Completed ¦

¦ or Received ¦

¦1. Inquiry Form...........: / / / / / / ¦

¦2. Acknowledgement Letter.: / / / / / / ¦

¦3. Needs Statement........: / / / / / / ¦

¦4. Program Statement......: / / / / / / ¦

¦5. Orientation Meeting....: / / / / / / ¦

¦6. Preservice Training....: / / / / / / ¦

¦7. Act #116...............: / / / / / / ¦

¦8. Licensing rules for ¦

¦ child placing agencies: / / / / / / ¦

¦9. Assessment Guide ¦

¦ Home & Community.......: / / / / / / ¦

¦10.Behavioral checklist...: / / / / / / ¦

¦11.Cross Race/Cross Cult..: / / / / / / ¦

¦12.Genogram...............: / / / / / / ¦

¦13.Summary of Findings/ ¦

¦ Excessive Concentration: / / / / / / ¦

¦14.Zoning Approval........: / / / / / / ¦

¦15.Environ. Health Inspec.: / / / / / / ¦

¦16.Admin. team review.....: / / / / / / ¦

¦17.Financial Statement....: / / / / / / ¦

¦ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -:Subtract a Day =:Today's Date¦

+ -X123456------Fos. Fam. # 5-----------+

¦ ¦

¦ Orientation Cont... Date Given Date Due Date Completed ¦

¦ or Received ¦

¦18.Foster Parent/Agency Agreement: / / / / / / ¦

¦19.Discipline Policy.............: / / / / / / ¦

¦20.Orientation Policy............: / / / / / / ¦

¦21.Initial Foster Home Lic. Eval.: / / / / / / ¦

¦22.Code Sheet....................: / / / / / / ¦

¦23.Contact Sheets................: / / / / / / ¦

¦24.FIA 3080......................: / / / / / / ¦

¦25.FIA 3706......................: / / / / / / ¦

¦26.Other: : / / / / / / ¦

¦ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -:Subtract a Day =:Today's Date¦

+ -X123456------Fos. Fam. # 6-----------+

¦ ¦

¦ Conditions for Application ¦

¦ Following Rule 205 these conditions must exist prior to receiving an ¦

¦ application: ¦

¦ ¦

¦ State whether condition exists and date for the following: ¦

¦ ¦

¦ a.) Applicant expressed a willingness to provide care to the children ¦

¦ served by the agency..............: ¦

¦ ¦

¦ b.) Applicant requested an application: ¦

¦ ¦

¦ Is this a two-parent home?............: ¦

¦ Date 1st parent signed application...: / / ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -X123456------Fos. Fam. # 7-----------+

¦ ¦

¦ Contacts With Foster Family ¦

¦ +------------------------------------------------------------------------+ ¦

¦ ¦ Date Type Purpose ¦ ¦

¦ ¦------------------------------------------------------------------------¦ ¦

¦ ¦ / / ¦ ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦ +------------------------------------------------------------------------+ ¦

¦ ¦

¦ Foster Family Members ¦

¦ +-----------------------------------------------------------------------+ ¦

¦ ¦ Name Relation Age ¦ ¦

¦ ¦-----------------------------------------------------------------------¦ ¦

¦ ¦ ¦ ¦ 1997 ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦ +-----------------------------------------------------------------------+ ¦

¦TABLE -+= Update Table = Leave Table ¦

+ -X123456------------------------------+

¦ ¦

¦ Foster Family Contacts ¦

¦ ¦

¦ Date of Contact...: / / ¦

¦ Status............: ¦

¦ Type of Contact...: Other: ¦

¦ Purpose of Contact: Other: ¦

¦ Worker............: ¦

¦ Persons Contacted.: ¦

¦ Duration..........: ¦

¦ Location..........: ¦

¦ ¦

¦ Describe what took place: ¦

¦ ¦

| ¦

¦ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -:Subtract a Day =:Today's Date¦

+ - ---------------Fos. Mem. # 1---------+

¦ ¦

¦ Information on Individual Family Members ¦

¦ ¦

¦ First name................: ¦

¦ Middle....................: ¦

¦ Last name.................: ¦

¦ Maiden or other...........: ¦

¦ Relationship to licensee..: ¦

¦ Specify: ¦

¦ Comments on Relationship..: ¦

¦ ¦

¦ Gender....................: Social Security #: - - ¦

¦ Date of Birth.............: / / Birth Cert. on file: ¦

¦ Race......................: other: ¦

¦ Hispanic origin...........: ¦

¦ Religion..................: other: ¦

¦ Marital Status............: ¦

¦ Please list all previous marriages including dates, places and decree or ¦

¦ document number(if deceased please include death cert. number as well) ¦

¦ ¦

¦ Hobbies/leisure activities: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ - ---------------Fos. Mem. # 2---------+

¦ For Adults ¦

¦ Is this person currently employed: ¦

¦ Current employer.................: ¦

¦ Description of job and job title.: ¦

¦ Schedule/hours...................: ¦

¦ Employer Phone...................: ( ) - ¦

¦ Other sources of income..........: ¦

¦ Annual Income....................: ¦

¦ Money Mgmt. skills...............: ¦

¦ Comments on Money Mgmt...........: ¦

¦ Date verification of medical insurance received: / / ¦

¦ Describe insurance, including health insurance: ¦

¦ ¦

¦ For Parents ¦

¦ Date verification of employment received: / / ¦

¦ Date of verification of other sources of income (if needed): / / ¦

¦ ¦

¦ For Adults For Children ¦

¦ Highest grade completed: Grade.: ¦

¦ School: ¦

¦ Comments on Education: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. # 3---------+

¦ ¦

¦ For Adults ¦

¦ Has a DSS 1326 for been sent out on this person: ¦

¦ Date sent......................................: / / ¦

¦ ¦

¦ Date conviction clearance returned.............: / / ¦

¦ Previous Convictions: ¦

¦ Explain: ¦

¦ ¦

¦ Date child abuse or neglect clearance returned.: / / ¦

¦ History of child abuse or neglect: ¦

¦ Explain ¦

¦ ¦

¦ Date previous license status returned..........: / / ¦

¦ ¦

¦ Has this person ever applied for a license before: ¦

¦ Explain: ¦

¦ ¦

¦ Date Medical clearance returned................: / / ¦

¦ Date self study form/assessment guide returned.: / / ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. # 4---------+

¦ For Licensees ¦

¦ Reasons for applying to be a foster parent: ¦

¦ Explain: ¦

¦ ¦

¦ In each of the following screens you should assess the foster family members.¦

¦ Explain and document your assessment in the explain sections. Please specify ¦

¦ the sources of your assessment (e.g. foster care worker, foster parent, ¦

¦ foster child, own observations) and give examples. ¦

¦ ¦

¦ All Family Members (Adults and Children) ¦

¦ Rate this persons current family functioning in each of the following areas: ¦

¦ (If a single individual look for contact with grown children or family) ¦

¦ 1) Communication.........................: ¦

¦ 2) Clarity & appropriateness of ¦

¦ roles & responsibilities..............: ¦

¦ 3) Respect...............................: ¦

¦ 4) Problem solving, crisis mgmt., ¦

¦ conflict resolution skills & practice.: ¦

¦ 5) Flexibility & adaptability to change..: ¦

¦ 6) Compatibility in the relationship of ¦

¦ adult caregivers......................: ¦

¦ Explain: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ - ---------------Fos. Mem. # 5---------+

¦ ¦

¦ Adults & Children Cont.... ¦

¦ ¦

¦ Rate this persons past family functioning in each of the following areas: ¦

¦ (If a single individual look for contact with grown children or family) ¦

¦ ¦

¦ 1) Communication.........................: ¦

¦ 2) Clarity & appropriateness of ¦

¦ roles & responsibilities..............: ¦

¦ 3) Respect...............................: ¦

¦ 4) Problem solving, crisis mgmt., ¦

¦ conflict resolution skills & practice.: ¦

¦ 5) Flexibility & adaptability to change..: ¦

¦ 6) Compatibility in the relationship of ¦

¦ adult caregivers......................: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. # 6---------+

¦ ¦

¦ Adults and Children Cont. ¦

¦ Summarize and assess the data listed on this individuals medical clearance ¦

¦ form as well as other information: ¦

¦ ¦

¦ Physical Health.: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Mental Health: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Emotional Health and Emotional Stability: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. # 7---------+

¦ ¦

¦ Adult & Child Cont.. ¦

¦ ¦

¦ Out of home placement as a child: ¦

¦ Describe.: ¦

¦ ¦

¦ Location of primary residence during childhood & composition of family ¦

¦ of origin: ¦

¦ ¦

¦ Describe strengths & limitations of family of origin: include description ¦

¦ and assessment of family roles, responsibilities, relationships, methods of ¦

¦ Communication, problem resolution, temperament, parenting & discipline ¦

¦ practices: ¦

¦ ¦

¦ Describe any family history of substance abuse, mental illness, criminal ¦

¦ convictions, child abuse or neglect, significant or traumatic experiences ¦

¦ during childhood or adolescence: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. # 8---------+

¦Parenting Skills, Including Attitudes Toward, and Methods of Discipline ¦

¦In the next few screens, there will be sub-topics related to child-caring ¦

¦skills. Within each, there are several fields for rating the family's current ¦

¦abilities. At the end of each sub-topic is an overall assessment in which you ¦

¦describe your ratings. Ratings must be supported with specific examples. ¦

¦ ¦

¦1) Protects the child from physical and psychological harm ¦

¦ ¦

¦ a) Maintains a hazard-free home and yard.............: ¦

¦ b) Familiarizes children with emergency and ¦

¦ evacuation plans..................................: ¦

¦ c) Ensures that the child is protected from strangers ¦

¦ and other persons who may harm the child..........: ¦

¦ d) Exercises good judgement in selecting alternate ¦

¦ care for the foster children......................: ¦

¦ e) Addresses special needs in this area..............: ¦

¦ f) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦ ¦

¦Overall assessment in protecting child/ren from harm...: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. # 9---------+

¦2) Promotes good physical health, growth, and development ¦

¦ a) Provides opportunities, encouragement, and good role ¦

¦ models to promote hygiene nutrition and exercise..: ¦

¦ b) Provides appropriate clothing and food............: ¦

¦ c) Initiates and follows through on child's needs for ¦

¦ physical/dental exams and treatments..............: ¦

¦ d) Cooperates with and notifies agency of progress or ¦

¦ problems related to child/ren's physical/dental ¦

¦ health............................................: ¦

¦ e) Submits all documentation related to physical/dental ¦

¦ health and medical treatment in a timely fashion..: ¦

¦ f) Schedules and provides all transportation needed to ¦

¦ attend to child/ren's physical/dental needs.......: ¦

¦ g) Has realistic and practical expectations of ¦

¦ child/ren based on age, abilities, and potential..: ¦

¦ h) Addresses children's special needs in this area...: ¦

¦ i) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦ j) Recognizes each child's unique health and dental ¦

¦ needs.............................................: ¦

¦Overall assessment of the promotion of physical health, etc...: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. #10---------+

¦ ¦

¦3) Promotes good social and emotional health, growth, and development ¦

¦ a) Recognizes each child's unique emotional growth ¦

¦ and development need..............................: ¦

¦ b) Provides opportunities, encouragement, and role ¦

¦ models to support open communication, positive ¦

¦ social activities and relationships...............: ¦

¦ c) Initiates and follows through on child/ren's need ¦

¦ for assessment and treatment in this area.........: ¦

¦ d) Cooperates with and notifies agency of progress or ¦

¦ problems related to child/ren's emotional ¦

¦ health/social development.........................: ¦

¦ e) Submits relevant documentation in a timely fashion: ¦

¦ f) Schedules and provides transportation needed to ¦

¦ attend child/ren's emotional and social needs.....: ¦

¦ g) Has realistic and practical expectations of each ¦

¦ child based on age, abilities, and potential......: ¦

¦ h) Addresses child/ren's special needs in this area..: ¦

¦ i) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦Overall assessment of the promotion of social and emotional health...: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. #11---------+

¦4) Promotes cognitive and educational growth and development ¦

¦ a) Recognizes each child's unique cognitive/intellectual ¦

¦ growth and developmental needs....................: ¦

¦ b) Provides opportunities, encouragement, and role ¦

¦ models to support learning, good study habits, and ¦

¦ intellectual curiosity............................: ¦

¦ c) Enrolls child in school within 5 days of placement ¦

¦ and makes sure child attends regularly and on time: ¦

¦ c) Initiates and follows through on child/ren's need ¦

¦ for special education assessment and treatment....: ¦

¦ d) Cooperates with and notifies agency and school of ¦

¦ progress or problems related to child/ren's ¦

¦ cognitive and educational growth and development..: ¦

¦ e) Submits relevant documentation in a timely fashion: ¦

¦ f) Schedules and provides transportation needed to ¦

¦ attend child/ren's cognitive and educational needs: ¦

¦ g) Has realistic and practical expectations of each ¦

¦ child based on age, abilities, and potential......: ¦

¦ h) Addresses child/ren's special needs in this area..: ¦

¦ i) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦Overall assessment of the promotion of cognitive and educational growth...: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. #12---------+

¦ ¦

¦5) Child Discipline ¦

¦ a) Sets appropriate limits and boundaries............: ¦

¦ b) Responds consistently to child/ren's appropriate ¦

¦ and inappropriate behaviors.......................: ¦

¦ c) Uses appropriate discipline techniques............: ¦

¦ d) Has realistic and practical expectations of each ¦

¦ child based on age, abilities, and potential......: ¦

¦ e) Uses Behavior Management methods to promote self ¦

¦ control, self esteem and independence in child/ren: ¦

¦ f) Cooperates with and notifies agency of progress or ¦

¦ problems related to child behavior management.....: ¦

¦ g) Addresses child/ren's special needs in this area..: ¦

¦ h) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦ ¦

¦Overall assessment of child discipline: ¦

¦ ¦

¦Overall assessment of Parenting Skills: ¦

¦Describe: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ---------------Fos. Mem. #13---------+

¦ ¦

¦ Parenting Skill Cont... ¦

¦ Attitudes toward discipline of children: ¦

¦ ¦

¦ Children Only ¦

¦ Areas of appropriate development/adjustment: ¦

¦ Areas of concern/problematic adjustment....: ¦

¦ Explain.: ¦

¦ ¦

¦ This child has needs in the following areas: ¦

¦ a) Cognitive development/condition.......: ¦

¦ b) Emotional/Social development/condition: ¦

¦ c) Physical development/condition........: ¦

¦ ¦

¦ Describe the child's needs: ¦

¦ ¦

¦ Expectations for this child................: ¦

¦ Describe: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ - ---------------Fos. Mem. #14---------+

¦ ¦

¦ Adults & Children ¦

¦ ¦

¦ Describe this persons strengths as they relate to the quality of care ¦

¦ received by foster children in this home: ¦

¦ ¦

¦ Describe this persons weakness' as they relate to the quality of care ¦

¦ received by foster children in this home: ¦

¦ ¦

+------------------------------------------------------------------------------¦

¦ Overall assessment of this person's evaluation...............: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -X123456-------Fos. Fam. # 8----------+

¦ ¦

¦ Placements During the Assessment Period ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦ Name D.O.B. Date In Date Out Current ¦ ¦

¦ ¦--------------------------------------------------------------------------¦ ¦

¦ ¦ ¦ / / ¦ / / ¦ / / ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦ ¦ ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

¦ ¦

¦ Foster Child Information ¦

¦ ¦

¦ Family name...: ¦

¦ First name....: DSS number...: ¦

¦ Last name.....: Program type.: ¦

¦ D.O.B.........: / / ¦

¦ Race..........: ¦

¦ Sex...........: ¦

¦ ¦

¦ Placement type: 0 ¦

¦ Date in.......: / / Date out: / / ¦

¦ ¦

¦ (The following is from intake, and cannot be changed here) ¦

¦ Grade.........: ¦

¦ School........: ¦

¦ ¦

¦ Educational Needs..............: 0 ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+------------------------------------------------------------------------------+

¦ Child's Needs ¦

¦ ¦

¦ This screen and the screens that follow document information about the ¦

¦ child as assessed at the 5-day report period and the last progress report ¦

¦ by Foster Care staff. The 5-day intake information can only be viewed. ¦

¦ The information from the last progress report can be edited as necessary. ¦

¦ Any changes you make remain in the Foster Family file and will not ¦

¦ influence the foster care record. ¦

¦ ¦

¦ In reading this information be sure that the role of the foster family in ¦

¦ addressing issues and the appropriateness of problem resolution is clearly ¦

¦ stated. ¦

¦ ¦

¦ Immediate and significant needs addressed in intake: ¦

¦ ¦

¦ <Press Any Key to Continue> ¦

¦ ¦

+------------------------------------------------------------------------------+

+----------------------------------------------------------------Screen #1----++

¦PROGRESS REPORT of : ¦¦

¦In the progress report please rate the child's situation in the domains of ¦¦

¦behavioral/emotional/psychiatric, educational, and health status. First ¦¦

¦you'll be asked to rate the child's situation as to whether he or she ¦¦

¦currently shows strength/appropriate development/or if this is an area of ¦¦

¦weakness. You will then be asked to explain your assessment with specific ¦¦

¦examples. Next you'll be asked to document significant issues faced in ¦¦

¦each domain and the adequacy of their resolution. ¦¦

¦ ¦¦

¦a) Behavioral/Emotional/Psychiatric Status: ¦¦

¦Rate the child's functioning over the report period: ¦¦

¦ ¦¦

¦Explain your assessment and give examples to document it. ¦¦

¦Part 1: ¦¦

¦Part 2: ¦¦

¦ ¦¦

¦Describe significant issues faced and the adequacy of their resolution, ¦¦

¦include input from agency staff, biological family and the child. ¦¦

¦ ¦¦

¦What was the foster families involvement in meeting the child's needs ¦¦

¦in this domain: ¦¦

¦Explain and give examples to document your assessment: ¦¦

¦ ¦¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+----------------------------------------------------------------Screen #2----++

¦PROGRESS REPORT of : ¦¦

¦ ¦¦

¦b) Educational Status ¦¦

¦ ¦¦

¦Current grade in school: ¦¦

¦ ¦¦

¦Rate the child's functioning over the report period: ¦¦

¦ ¦¦

¦Explain your assessment and give examples to document it. ¦¦

¦ ¦¦

¦Date of last school report: / / ¦¦

¦ ¦¦

¦Describe significant issues faced and the adequacy of their resolution, ¦¦

¦include input from agency staff, biological family and the child. ¦¦

¦ ¦¦

¦What was the foster family's involvement in meeting the child's needs ¦¦

¦in this domain: ¦¦

¦Explain and give examples to document your assessment: ¦¦

¦ ¦¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+----------------------------------------------------------------Screen #3----++

¦PROGRESS REPORT of : ¦¦

¦c) Health Status (Dental/Medical) ¦¦

¦ ¦¦

¦Rate the child's functioning over the report period: ¦¦

¦ ¦¦

¦Explain your assessment of the child's general health status and give ¦¦

¦examples to document it, including findings from last medical-dental checkup:¦¦

¦ ¦¦

¦Date of last medical checkup: Date of next scheduled medical checkup: ¦¦

¦ / / / / ¦¦

¦ ¦¦

¦Date of last dental checkup: Date of next scheduled dental checkup: ¦¦

¦ / / / / ¦¦

¦ ¦¦

¦Describe significant issues faced and the adequacy of their resolution, ¦¦

¦include input from agency staff, biological family and the child. ¦¦

¦ ¦¦

¦What was the foster family's involvement in meeting the child's needs ¦¦

¦in this domain: ¦¦

¦Explain and give examples to document your assessment: ¦¦

¦ ¦¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+----------------------------------------------------------------Screen #4----++

¦PROGRESS REPORT of : ¦¦

¦ ¦¦

¦Child's current functioning in the family as this is supported by the ¦¦

¦foster family. ¦¦

¦ ¦¦

¦On the screens that follow you will be asked to rate, in the first column, ¦¦

¦the extent to which this child exhibits age appropriate capacities where: ¦¦

¦ 1 = weakness, needs support of foster parent and therapeutic intervention ¦¦

¦ 2 = limitations, needs support of foster parent ¦¦

¦ 3 = age appropriate ¦¦

¦ 4 = shows strength ¦¦

¦ ¦¦

¦In the second column you will be asked to rate the extent to which the ¦¦

¦foster parent is supportive or provides appropriate resources to support ¦¦

¦the child's functioning where: ¦¦

¦ 1 = area of weakness, foster parent needs help in working with this child ¦¦

¦ 2 = appropriate levels of support or resource provision ¦¦

¦ 3 = shows strength, foster parent is particularly helpful in this domain ¦¦

¦ with this child ¦¦

¦ ¦¦

¦ <Press any key to continue> ¦¦

+-----------------------------------------------------------------------------+¦

+----------------------------------------------------------------Screen #5----++

¦PROGRESS REPORT of : ¦¦

¦ ¦¦

¦Child's current functioning in the family as this is supported by the ¦¦

¦foster family. ¦¦

¦ ¦¦

¦1) Attachment relationships and interactions ¦¦

¦ ¦¦

¦ a) with same age peers. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ b) with other foster children in the home. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ c) foster family. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ d) siblings. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ e) biological family. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+----------------------------------------------------------------Screen #6----++

¦PROGRESS REPORT of : ¦¦

¦ ¦¦

¦Child's current functioning in the family as this is supported by the ¦¦

¦foster family. ¦¦

¦ ¦¦

¦2) Problem solving ability, persistence ¦¦

¦ ¦¦

¦ a) in relationships at foster home. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ b) in other social situations. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ c) at school. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ d) with regard to homework. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+----------------------------------------------------------------Screen #7----++

¦PROGRESS REPORT of : ¦¦

¦ ¦¦

¦Child's current functioning in the family as this is supported by the ¦¦

¦foster family. ¦¦

¦ ¦¦

¦3) Flexibility and adaptability to change ¦¦

¦ ¦¦

¦ a) in relationships at foster home. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ b) in other social situations. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ c) at school. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ d) with regard to homework. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+----------------------------------------------------------------Screen #8----++

¦PROGRESS REPORT of : ¦¦

¦ ¦¦

¦Child's current functioning in the family as this is supported by the ¦¦

¦foster family. ¦¦

¦ ¦¦

¦4) Psychological development. ¦¦

¦ ¦¦

¦ a) Sense of mastery, autonomy. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ b) Sense of humor. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦ c) Positive self regard. ¦¦

¦ Child shows: Parent provides: ¦¦

¦ ¦¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

****COMPLAINTS AND INVESTIGATION SCREENS TO BE ADDED****

+ -X123456------Fos. Fam. # 9-----------+

¦ ¦

¦ Foster Family Complaint Investigations ¦

¦ +----------------------------------------------------------------------+ ¦

¦ ¦ Date Nature Type Priority ¦ ¦

¦ ¦----------------------------------------------------------------------¦ ¦

¦ ¦ / / ¦ ¦ ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦ ¦

¦ +----------------------------------------------------------------------+ ¦

¦ All foster family complaint investigations should trigger rule ¦

¦ compliance investigation using the table below. ¦

¦ Investigation of Alleged Rule Non-compliance ¦

¦ +-------------------------------------------------------------------+ ¦

¦ ¦ Date ¦ ¦

¦ ¦-------------------------------------------------------------------¦ ¦

¦ ¦ / / ¦ ¦

¦ ¦ ¦ ¦

¦ +-------------------------------------------------------------------+ ¦

¦TABLE -+= Update Table = Leave Table ¦

+ -X123456------Fos. Fam. #10-----------+

¦ HOME STUDY ¦

¦ ¦

¦NEIGHBORHOOD AND COMMUNITY: ¦

¦ ¦

¦Describe the type of neighborhood where home is located. Note if location is ¦

¦in the city, suburb, small town, or rural area. ¦

¦ ¦

¦Describe the socio-economic, racial, and cultural composition of the ¦

¦neighborhood: ¦

¦ ¦

¦Are there playgrounds and other recreational facilities nearby? ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -X123456------Fos. Fam. #11-----------+

¦HOME STUDY (neighborhood and community) ¦

¦ ¦

¦Schools: ¦

¦Name the local elementary, middle, and high schools. For each provide address,¦

¦phone numbers, and indicate whether and how they provide transportation: ¦

¦ ¦

¦SUMMARY ASSESSMENT of this neighborhood, its schools, recreational and medical¦

¦facilities and their adequacy for the purpose of providing foster care: ¦

¦ ¦

¦Physician utilized for routine care of Foster Children: ¦

¦Name....: ¦

¦Facility: ¦

¦Address.: ¦

¦Phone...: ( ) - ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -X123456------Fos. Fam. #12-----------+

¦HOME STUDY ¦

¦ ¦

¦DESCRIPTION OF THE HOME ¦

¦ ¦

¦Provide complete description of the home, its type (ranch, apartment,...) ¦

¦and the number and type of rooms it contains (excluding bedrooms): ¦

¦ ¦

¦Sleeping Arrangements: For each of the bedrooms in the house, describe its ¦

¦measurements, square footage, location in home, number and types of beds in ¦

¦the room, the occupants, and any other pertinent information. ¦

¦ ¦

¦Describe and assess housekeeping standards: Who is responsible for the various¦

¦housekeeping tasks, how frequently these tasks are performed, the degree to ¦

¦which the home is clean, well organized, and hazard-free: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -X123456------Fos. Fam. #13-----------+

¦HOME STUDY (Description of the home) ¦

¦ ¦

¦Is this home of Barrier-Free Design? ¦

¦Describe: ¦

¦ ¦

¦Are there pets in the home? ¦

¦Describe: ¦

¦ ¦

¦Are family members familiar with emergency and evacuation plans? ¦

¦ ¦

¦Is this a Non-Smoking House? ¦

¦ ¦

¦Is yard fenced? Is it suitable for children's outdoor play? ¦

¦ ¦

¦Summary assessment of the adequacy of this home and yard for the purpose of ¦

¦providing foster care: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -X123456-------Fos. Fam. #14----------+

¦ ¦

¦ Home Study Cont. ¦

¦ ¦

¦ Routine family activities........: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Family's ability to meet the needs of a child of another faith: ¦

¦ Rate the family's ability to meet the needs of a child of ¦

¦ another faith where Strength = current contact with various ¦

¦ churches, religious leaders, current interaction with these groups; ¦

¦ Appropriate level = willing to make contact, take child ¦

¦ to events, has access to information; Limitation = needs help feeling ¦

¦ comfortable or finding contacts: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ -X123456------Fos. Fam. #15-----------+

¦ ¦

¦ Foster Family Information Cont. ¦

¦ ¦

¦ Family's perception of the purpose of foster care: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Family's attitude toward accepting and working with a foster child: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Family's attitude toward the foster child's family: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ -X123456------Fos. Fam. #16-----------+

¦ ¦

¦ Summary of References (not related) for the Licensee ¦

¦ ¦

¦ Name.........: ¦

¦ Date Received: / / ¦

¦ Summary of 1st reference: ¦

¦ ¦

¦ Name.........: ¦

¦ Date Received: / / ¦

¦ Summary of 2nd reference: ¦

¦ ¦

¦ Name.........: ¦

¦ Date Received: / / ¦

¦ Summary of 3rd reference: ¦

¦ ¦

¦ Other References ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ -X123456------Fos. Fam. #17-----------+

¦SUMMARY AND RECOMMENDATIONS: ¦

¦Describe the foster family's STRENGTHS as they relate to each of the main ¦

¦tasks of foster care: ¦

¦ ¦

¦Describe the foster family's WEAKNESSES as they relate to each of the main ¦

¦tasks of foster care: ¦

¦ ¦

¦Describe the foster family's TRAINING NEEDS as IDENTIFIED BY AGENCY relating ¦

¦to the following areas: ¦

¦ ¦

¦Describe the foster family's TRAINING NEEDS as IDENTIFIED BY FAMILY relating ¦

¦to the following areas: ¦

¦ ¦

¦Additional comments: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ -X123456------Fos. Fam. #18-----------+

¦SUMMARY AND RECOMMENDATIONS (continued): ¦

¦ ¦

¦Has the family expressed an interest in fostering cross-racially or cross- ¦

¦culturally? ¦

¦ ¦

¦Describe the foster family's STRENGTHS in the domain of cross-racial or ¦

¦cross-cultural fostering: ¦

¦ ¦

¦Describe the foster family's WEAKNESSES in the domain of cross-racial or ¦

¦cross-cultural fostering: ¦

¦ ¦

¦Agency recommendation for cross-racial or cross-cultural fostering: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -X123456------Fos. Fam #19------------+

¦ ¦

¦ Cross Cultural Training ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦ Topic Date Location ¦ ¦

¦ ¦--------------------------------------------------------------------------¦ ¦

¦ ¦ ¦ / / ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

+ -X123456------Fos. Fam #19------------+

¦ ¦

¦ +----------------------------------------------------------------------+ ¦

¦ ¦ T R A I N I N G ¦ ¦

¦ +-¦ ¦-+ ¦

¦ ¦ ¦Date......: / / ¦ ¦ ¦

¦ ¦-¦ ¦-¦ ¦

¦ ¦Status....: ¦ ¦

¦ ¦ ¦Location..: ¦ ¦ ¦

¦ ¦ ¦Credits...: ¦ ¦ ¦

¦ ¦ ¦Attendee..: ¦ ¦ ¦

¦ ¦ ¦Domain....: ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦ ¦ +----------------------------------------------------------------------+ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -:Subtract a Day =:Today's Date¦

+ -X123456----------Fos. Fam #20--------+

¦PRIMARY ALTERNATE CHILD CARE PROVIDER ¦

¦Provider Name.............: ¦

¦ ¦

¦Relationship to Foster Family: Other: ¦

¦ ¦

¦Address......................: ¦

¦City/State...................: Zip Code: ¦

¦Directions to Home/facility..: ¦

¦ ¦

¦Primary Phone: ( ) - ¦

¦Other Phone..: ( ) - Name: ¦

¦ ¦

¦Local Hospital: ¦

¦ ¦

¦Barrier Free Design? Non Smoking House? ¦

¦ ¦

¦Comments (Describe and assess issues such as hours and frequency of use; ¦

¦Medical and record clearance on file; concerns, etc...): ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ -X123456------------Fos. Fam #21------+

¦SECONDARY ALTERNATE CHILD CARE PROVIDER ¦

¦Provider Name.............: ¦

¦ ¦

¦Relationship to Foster Family: Other: ¦

¦ ¦

¦Address......................: ¦

¦City/State...................: Zip Code: ¦

¦Directions to Home/facility..: ¦

¦ ¦

¦Primary Phone: ( ) - ¦

¦Other Phone..: ( ) - Name: ¦

¦ ¦

¦Local Hospital: ¦

¦ ¦

¦Barrier Free Design? Non Smoking House? ¦

¦ ¦

¦Comments (Describe and assess issues such as hours and frequency of use; ¦

¦Medical and record clearance on file; concerns, etc...): ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ -X123456------Fos. Fam. #22-----------+

¦ ¦

¦ Type of children who may be placed with this family ¦

¦ ¦

¦ This family is licensed for the following: ¦

¦ ¦

¦ Provider Type....: ¦

¦ Capacity.........: ¦

¦ Gender...........: ¦

¦ Race.............: other: ¦

¦ Age Range........: ¦

¦ ¦

¦ Child/ren with special needs regarding: ¦

¦ a) Cognitive development/condition.......: ¦

¦ b) Emotional/Social development/condition: ¦

¦ c) Physical development/condition........: ¦

¦ ¦

¦ Comments regarding children who may be placed with this family: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ -X123456------Fos. Fam. #23-----------+

¦ ¦

¦ Type of children who may not be placed with this family ¦

¦ ¦

¦ This family is not licensed for the following: ¦

¦ ¦

¦ Gender...........: ¦

¦ Race.............: other: ¦

¦ Age Range........: ¦

¦ ¦

¦ Child/ren with special needs regarding: ¦

¦ a) Cognitive development/condition.......: ¦

¦ b) Emotional/Social development/condition: ¦

¦ c) Physical development/handicap.........: ¦

¦ ¦

¦ Comments on children who are not appropriate for this family: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -X123456------Fos. Fam. #24-----------+

¦ ¦

¦ Type of child/ren preferred by this family ¦

¦ ¦

¦ The following is what the family would prefer: ¦

¦ ¦

¦ Provider Type....: ¦

¦ Capacity.........: ¦

¦ Gender...........: ¦

¦ Race.............: other: ¦

¦ Age Range........: ¦

¦ ¦

¦ Comments on type of children this family would prefer: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -X123456-------Fos. Fam. #25----------+

¦ ¦

¦ Date Initial Evaluation Given to Family: / / ¦

¦ ¦

¦ Original Date of Licensure..........: / / ¦

¦ ¦

¦ Date of Transfer to this Agency.....: / / ¦

¦ Date of Most Recent Re-open.........: / / ¦

¦ Effective Date of Current License...: / / ¦

¦ Expiration Date of Current License..: / / ¦

¦ Annual Reevaluation Date............: / / ¦

¦ Interim/Follow Up Date..............: / / ¦

¦ ¦

¦ Name of Licensing Social Worker.....: ¦

¦ ¦

¦ Additional Comments.................: ¦

¦ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -: Substract a Day =:Today's Date¦

APPENDIX II

The major screens for the adoption module follow. Specific instructions for single and multiple list texts are not included. The first set of screens involves prospective adoptive parents and the second set of screens involves children being freed for adoption.

+------------------------------------------------------------------------------+

¦ Select the type of update ¦

¦ A D O P T I V E P A R E N T S ¦

¦ +------------------------------------+ ¦

¦ ¦1-Full Form ¦ ¦

¦ ¦2-Family Information ¦ ¦

¦ ¦3-Orientation ¦ ¦

¦ ¦4-Contacts ¦ ¦

¦ ¦5-Family Members ¦ ¦

¦ ¦6-Home Study ¦ ¦

¦ ¦7-Assessment of Child Caring Skills ¦ ¦

¦ ¦8-References ¦ ¦

¦ ¦9-Placement Info ¦ ¦

¦ +------------------------------------+ ¦

¦ ¦

¦LIST (single choice) -+= Choose Input Code F8= Empty Field = Up & Down list¦

+---------------------------------------------------------------Adopt. # 1-----+

¦ ¦

¦ Adoptive Family Home Assessment ¦

¦ ¦

¦ Adoptive Family Information ¦

¦ ¦

¦ Family Name: ¦

¦ Family No..: S223456 ¦

¦ ¦

¦ Street.....: ¦

¦ City.......: ¦

¦ State......: ¦

¦ Zip........: - ¦

¦ Phone......: ¦

¦ ¦

¦ Is this inquiry about a specific child? ¦

¦ ¦

¦ Is this child a relative, or currently being fostered by this family? ¦

¦ ¦

¦ Number of months with this family (including temporary wardship): 0 ¦

¦ ¦

¦ Name of agency: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ -S223456 ----------------------Adopt. # 2-----+

¦ ¦

¦ Orientation ¦

¦ Following Rule 519 (August, 1995), the following information must be ¦

¦ provided before scheduling home study. ¦

¦ ¦

¦ For each item, indicate if provided, and the date: ¦

¦ ¦

¦ (a) The agency adoption program, policies and procedures..............: ¦

¦ (b) The needs and characteristics of children available for adoption..: ¦

¦ (c) Attachment and separation issues for children and families........: ¦

¦ (d) The importance of racial and cultural identity to the ¦

¦ child and ways to foster this identity............................: ¦

¦ (e) The impact of adoption on the child and family....................: ¦

¦ (f) The adoption process..............................................: ¦

¦ (g) The rights and responsibilities of the adoptive family and agency.: ¦

¦ (h) The legal process for adoption....................................: ¦

¦ (i) The services and resources available to the adoptive family.......: ¦

¦ (j) Fees and charges for adoption services ¦

¦ pursuant to the provisions of R 400.12503(d)......................: ¦

¦ (k) The adoption subsidy program administered by the department.......: ¦

¦ (l) The provisions of Act No. 204 of Public Acts of 1994 (children's ¦

¦ ombudsman act)....................................................: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -S223456 ----------------------Adopt. # 3-----+

¦ ¦

¦ Contacts ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦ Date Location ¦ ¦

¦ ¦--------------------------------------------------------------------------¦ ¦

¦ ¦ / / ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

+------------------------------------------------------------------------------+

¦ ¦

¦ Date of contact...............: / / ¦

¦ Status........................: ¦

¦ Duration......................: ¦

¦ People interviewed or observed: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Worker..: ¦

¦ ¦

¦ Location: ¦

¦ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -:Subtract a Day =:Today's Date¦

+ -S223456 ----------------------Adopt. # 4-----+

¦ ¦

¦ Parents ¦

¦ +-------------------------------------------------------+ ¦

¦ ¦ Name Age ¦ ¦

¦ ¦-------------------------------------------------------¦ ¦

¦ ¦ ¦ 1997 ¦ ¦

¦ ¦ ¦ ¦ ¦

¦ +-------------------------------------------------------+ ¦

¦ ¦

¦ Children (under 18 only) ¦

¦ +-----------------------------------------------------+ ¦

¦ ¦ Name Age ¦ ¦

¦ ¦-----------------------------------------------------¦ ¦

¦ ¦ ¦ 1997 ¦ ¦

¦ ¦ ¦ ¦ ¦

¦ +-----------------------------------------------------+ ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

+-------------------------------------------------------------Ad. Par #1-------+

¦ Parental Information Screens ¦

¦ ¦

¦ Mother/Father..........: ¦

¦ ¦

¦ Last name..............: ¦

¦ First name.............: ¦

¦ Middle name............: ¦

¦ ¦

¦ Maiden or other........: ¦

¦ Mother's name..........: ¦

¦ Father's name..........: ¦

¦ ¦

¦ Social Security number.: - - ¦

¦ D.O.B..................: / / ¦

¦ ¦

¦ Race...................: ¦

¦ Hispanic origin........: ¦

¦ Religion...............: ¦

¦ ¦

¦ Hobbies/leisure activities: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - -----Ad. Par #2-------+

¦ ¦

¦ Parental Information (continued) ¦

¦ ¦

¦ Current marital status.: ¦

¦ ¦

¦ Previous Marriages ¦

¦ +------------------------------------------------------------------+ ¦

¦ ¦ Date Marriage Began Date Marriage Ended ¦ ¦

¦ ¦------------------------------------------------------------------¦ ¦

¦ ¦ 07/20/96 ¦07/19/96 ¦ ¦

¦ ¦ ¦ ¦ ¦

¦ +------------------------------------------------------------------+ ¦

¦ ¦

¦ Comments reguarding previous marriages: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - -----Ad. Par #3-------+

¦ Parental Information (continued) ¦

¦ ¦

¦ Employment and income information ¦

¦ ¦

¦ Current Employer.......: ¦

¦ Description of Job and Job Title: ¦

¦ ¦

¦ Other Sources of Income: ¦

¦ Annual Income..........: ¦

¦ ¦

¦ Money Mgmt. Skills.....: ¦

¦ Financial report given.: ¦

¦ Date Given.............: / / ¦

¦ ¦

¦ Date verification of employment received.......: / / ¦

¦ Date verification of medical insurance received: / / ¦

¦ Describe insurance, including health insurance.: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ - -----Ad. Par #4-------+

¦ ¦

¦ Following Rule 511 the following information must be collected ¦

¦ ¦

¦ Reasons for adopting: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ - -----Ad. Par #5-------+

¦ Rule 511 continued... ¦

¦ ¦

¦ The following section focuses on this parent's current family functioning. ¦

¦ For each area, a-f, assess whether this parent is at an appropriate level ¦

¦ or shows unusual strength or exhibits weaknesses and limitations. Use the ¦

¦ 'explain' section to document the bases for your assessment. Include your ¦

¦ own observations, statements by this parent and information from other ¦

¦ sources. ¦

¦ ¦

¦ (a) Communication.........................: ¦

¦ (b) Clarity and appropriateness of ¦

¦ roles and responsibilities............: ¦

¦ (c) Display of affection, compatibility ¦

¦ respect and positive feelings.........: ¦

¦ (d) Problem solving, crisis mgmt., conflict ¦

¦ resolution skills and practice........: ¦

¦ (e) Flexibility and adaptability to change: ¦

¦ (f) Compatibility in the relationship of ¦

¦ adult caregivers......................: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - -----Ad. Par #6-------+

¦ Rule 511 continued... ¦

¦ Previous experience in providing child foster care, child day care or ¦

¦ adult foster care................: ¦

¦ ¦

¦ Attitude toward working with child's relatives and previous caregivers: ¦

¦ ¦

¦ Describe the following as they relate to this parent's ability to provide ¦

¦ child care. Use the 'Explain' section to document the basis for your ¦

¦ assessment. Include information from your own observations, statements by ¦

¦ this parent and other sources such as records. ¦

¦ ¦

¦ Current state of physical health: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Current state of mental health and emotional stability: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Current state of emotional health: ¦

¦ ¦

¦ Explain: ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ - -----Ad. Par #7-------+

¦ Rule 511 continued... ¦

¦ ¦

¦ Was person ever placed out of home........................: ¦

¦ Explain: ¦

¦ ¦

¦ Relationship with own parents ¦

¦ Rate the extent that each of the following describes the relationship. ¦

¦ Use the 'Explain' section to document your assessment, providing specific ¦

¦ examples. ¦

¦ ¦

¦ Provides a sound basis for own parenting..: ¦

¦ Explain: ¦

¦ Is appropriately warm and affectionate....: ¦

¦ Explain: ¦

¦ Is a source of support....................: ¦

¦ Explain: ¦

¦ ¦

¦ Summarize this parent's parenting skills, including their behavior ¦

¦ management techniques and attitudes about discipline: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - -----Ad. Par #8-------+

¦ ¦

¦ Rule 511 continued... ¦

¦ ¦

¦ This parent's capacity and disposition to give ¦

¦ love, affection, and guidance: ¦

¦ ¦

¦ This parent's capacity and disposition to educate and create an atmosphere ¦

¦ that fosters the religion, racial-ethnic identity and culture ¦

¦ of the adopted child.........: ¦

¦ ¦

¦ Explain the above: ¦

¦ ¦

¦ Parent's attitude toward the birth family...........: ¦

¦ Parent's attitude toward accepting an adoptive child: ¦

¦ Explain: ¦

¦ ¦

¦ Parent's plans to discuss adoption with adopted child: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - -----Ad. Par #9-------+

¦ Rule 511 continued... ¦

¦ ¦

¦ Does this parent have any previous criminal convictions..........: ¦

¦ Explain: ¦

¦ ¦

¦ Does this parent have a history of substantiated abuse or neglect: ¦

¦ Explain: ¦

¦ ¦

¦ Describe parent's strengths as they relate to child care: ¦

¦ ¦

¦ Describe parent's weaknesses as they relate to child care: ¦

¦ ¦

¦ Overall assessment of this person's ability to parent an adoptive child. ¦

¦ If assessment focuses on a particular child, note this. ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+-----------------------------------------------------------Ad. Child #1-------+

¦ ¦

¦ Children's Information ¦

¦ ¦

¦ First Name: ¦

¦ Last Name.: ¦

¦ D.O.B.....: / / ¦

¦ Relation..: Other: ¦

¦ Gender....: Social Security Number: - - ¦

¦ ¦

¦ Grade..................: ¦

¦ School.................: ¦

¦ Highest grade completed: 0 ¦

¦ Comments on education..: ¦

¦ ¦

¦ Hobbies and activities.: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ - --Child #2-------+

¦ ¦

¦ Following Rule 511 the following information must be collected ¦

¦ ¦

¦ Rate this child's current family functioning in ¦

¦ each of the following domains: ¦

¦ ¦

¦ (a) Communication..........................: ¦

¦ (b) Clarity and appropriateness of ¦

¦ roles and responsibilities.............: ¦

¦ (c) Display of affection, compatibility, ¦

¦ respect and positive feelings..........: ¦

¦ (d) Problem solving, crisis mgmt., conflict ¦

¦ resolution skills and practice.........: ¦

¦ (e) Flexibility and adaptability to change: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - --Child #3-------+

¦ ¦

¦ Rule 511 continued... ¦

¦ ¦

¦ Assess the following with regard to family's ability to parent an adoptive ¦

¦ child. Depending on the age of the child, health conditions can affect the ¦

¦ parent's ability to care for another child and/or the child's ability to ¦

¦ become involved with the adoptive child. ¦

¦ ¦

¦ Child's current physical health: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Child's current mental health and emotional stability: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Child's current emotional health: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - --Child #4-------+

¦ ¦

¦ Rule 511 continued... ¦

¦ ¦

¦ Has child ever been placed out of home: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Describe and assess this child's relationship with his/her parents and ¦

¦ siblings as it relates to the family's ability to parent a foster child. ¦

¦ Document the bases for your assessments in the 'Explain' section by noting ¦

¦ what you observed, what you were told by the child, his or her parents, ¦

¦ siblings and other, as well as any other sources of information. ¦

¦ ¦

¦ Child's relation with parents.........: ¦

¦ Explain: ¦

¦ ¦

¦ Child's relation with other siblings.: ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - --Child #5-------+

¦ ¦

¦ Rule 511 continued... ¦

¦ ¦

¦ Describe and assess the domains of childhood development in which this child ¦

¦ displays appropriate adjustment or strengths and the domains in which this ¦

¦ child has current or ongoing needs. Document the bases for your assessment ¦

¦ in the 'Explain' section by noting specific examples, observations or ¦

¦ information from other sources. ¦

¦ ¦

¦ Child's adjustment....................: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Child's needs.........................: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ - --Child #6-------+

¦ Rule 511 continued... ¦

¦ ¦

¦ As age appropriate, assess this child's capacity to provide love and ¦

¦ affection to the adopted child...................: ¦

¦ ¦

¦ As age appropriate, assess this child's capacity to accept and enhance a ¦

¦ home atmosphere that fosters the religious, racial-ethnic and cultural ¦

¦ identity of the adopted child....................: ¦

¦ ¦

¦ Explain your assessment, provide specific examples, observations and ¦

¦ other sources of information. ¦

¦ ¦

¦ Attitude of the child toward the adopted child's birth family. ¦

¦ ¦

¦ Attitude of the child in accepting an adoptive child. ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+-----------------------------------------------------------Ad. Child #7-------+

¦ ¦

¦ Child information Continued ¦

¦ ¦

¦ Describe this child's strengths as they relate to this family's ability ¦

¦ to care for an adoptive child: ¦

¦ ¦

¦ Describe this child's weaknesses as they relate to this family's ability ¦

¦ to care for an adoptive child: ¦

¦ ¦

¦ Overall evaluation of child: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -S223456 ----------------------Adopt. # 5-----+

¦ ¦

¦ Other Adults in the House ¦

¦ +--------------------------------------------------------------+ ¦

¦ ¦ Name Age ¦ ¦

¦ ¦--------------------------------------------------------------¦ ¦

¦ ¦ ¦ 1997 ¦ ¦

¦ ¦ ¦ ¦ ¦

¦ +--------------------------------------------------------------+ ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

+---------------------------------------------------------Ad. Other #1---------+

¦ ¦

¦ Other Adults Information ¦

¦ ¦

¦ Last Name..............: ¦

¦ First Name.............: ¦

¦ Middle.................: ¦

¦ ¦

¦ Gender.................: Social Security Number: - - ¦

¦ D.O.B..................: / / ¦

¦ ¦

¦ Race...................: ¦

¦ Hispanic origin........: ¦

¦ Religion...............: ¦

¦ ¦

¦ Highest Grade Completed: ¦

¦ ¦

¦ Hobbies and leisure activities: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ - ------Ad. Other #2---------+

¦ ¦

¦ Other Adult Information (continued) ¦

¦ ¦

¦ Current marital status.: ¦

¦ ¦

¦ Previous Marriages ¦

¦ +------------------------------------------------------------------+ ¦

¦ ¦ Date Marriage Began Date Marriage Ended ¦ ¦

¦ ¦------------------------------------------------------------------¦ ¦

¦ ¦ 07/20/96 ¦07/19/96 ¦ ¦

¦ ¦ ¦ ¦ ¦

¦ +------------------------------------------------------------------+ ¦

¦ ¦

¦ Comments reguarding previous marriages: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - -------Ad. Other #3-------+

¦ Other Adult Information (continued) ¦

¦ ¦

¦ Employment and income information ¦

¦ ¦

¦ Current Employer.......: ¦

¦ Description of Job and Job Title: ¦

¦ Employment history.....: ¦

¦ ¦

¦ Other Sources of Income: ¦

¦ Annual Income..........: ¦

¦ ¦

¦ Money Mgmt. Skills.....: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ - ------Ad. Other #4---------+

¦ ¦

¦ Following Rule 511 the following information must be collected ¦

¦ ¦

¦ The following section focuses on this parent's current family functioning. ¦

¦ For each area, a-f, assess whether this parent is at an appropriate level ¦

¦ or shows unusual strength or exhibits weaknesses and limitations. Use the ¦

¦ 'explain' section to document the bases for your assessment. Include your ¦

¦ own observations, statements by this parent and information from other ¦

¦ sources. ¦

¦ ¦

¦ (a) Communication..........................: ¦

¦ (b) Clarity & appropriateness of roles & ¦

¦ responsibilities.......................: ¦

¦ (c) Display of affection, compatability, ¦

¦ respect & positive feelings............: ¦

¦ (d) Problem solving, crisis mgmt., conflict ¦

¦ resolution skills & practice...........: ¦

¦ (e) Flexibility and adaptability to change.: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ------Ad. Other #5---------+

¦ ¦

¦ Rule 511 continued... ¦

¦ ¦

¦ Person's current physical health: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Person's current mental health and emotional stability: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Person's current emotional health: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ------Ad. Other #6---------+

¦ ¦

¦ Rule 511 continued... ¦

¦ ¦

¦ Has person ever been placed out of home..........: ¦

¦ Explain: ¦

¦ ¦

¦ Person's relation with parent/primary care givers: ¦

¦ Explain: ¦

¦ ¦

¦ Capacity and disposition of this person to give the ¦

¦ Adopted child love, affection and guidance.......: ¦

¦ ¦

¦ Capacity and dispositon of this person to educate ¦

¦ and create an atmosphere that fosters the religion, ¦

¦ racial identity, and culture of the adopted child: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ------Ad. Other #7---------+

¦ ¦

¦ Rule 511 continued... ¦

¦ ¦

¦ Attitude of this person toward the child's birth family: ¦

¦ Attitude of this person in accepting an adoptive child.: ¦

¦ Explain: ¦

¦ ¦

¦ Plans to discuss adoption with the adoptive child......: ¦

¦ Explain: ¦

¦ ¦

¦ Does this person have a record of criminal convictions.: ¦

¦ Explain: ¦

¦ ¦

¦ Does this person have a past history of substantiated ¦

¦ abuse or neglect.......................................: ¦

¦ Explain: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ - ------Ad. Other #8---------+

¦ ¦

¦ Other Adult Information (continued) ¦

¦ ¦

¦ Any history of previous involvement in adoption process: ¦

¦ Explain: ¦

¦ ¦

¦ Record and assess any previous experience in providing child foster care, ¦

¦ child day care, or adult foster care...................: ¦

¦ ¦

¦ This adult's strengths in providing child care..........: ¦

¦ ¦

¦ This adult's weaknesses in providing child care..........: ¦

¦ ¦

¦ Overall assess this adult's evaluation.................: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -S223456 ----------------------Adopt. #6------+

¦ HOME STUDY ¦

¦ ¦

¦NEIGHBORHOOD AND COMMUNITY: ¦

¦ ¦

¦Describe the type of neighborhood where home is located. Note if location is ¦

¦in the city, suburb, small town, or rural area. ¦

¦ ¦

¦Describe the socio-economic, racial, and cultural composition of the ¦

¦neighborhood: ¦

¦ ¦

¦Are there playgrounds and other recreational facilities nearby? ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -S223456 ----------------------Adopt. #7------+

¦HOME STUDY (neighborhood and community) ¦

¦ ¦

¦Schools: ¦

¦Name the local elementary, middle, and high schools. For each provide address,¦

¦phone numbers, and indicate whether and how they provide transportation: ¦

¦ ¦

¦SUMMARY ASSESSMENT of this neighborhood, its schools, recreational and medical¦

¦facilities and their adequacy for the purpose of providing foster care: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -S223456 ----------------------Adopt. # 8-----+

¦HOME STUDY ¦

¦ ¦

¦DESCRIPTION OF THE HOME ¦

¦ ¦

¦Provide complete description of the home, its type (ranch, apartment,...) ¦

¦and the number and type of rooms it contains (excluding bedrooms): ¦

¦ ¦

¦Sleeping Arrangements: For each of the bedrooms in the house, describe its ¦

¦measurements, square footage, location in home, number and types of beds in ¦

¦the room, the occupants, and any other pertinent information. ¦

¦ ¦

¦Describe and assess housekeeping standards: Who is responsible for the various¦

¦housekeeping tasks, how frequently these tasks are performed, the degree to ¦

¦which the home is clean, well organized, and hazard-free: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -S223456 ----------------------Adopt. # 9-----+

¦HOME STUDY (Description of the home) ¦

¦ ¦

¦Is this home of Barrier-Free Design? ¦

¦Describe: ¦

¦ ¦

¦Are there pets in the home? ¦

¦Describe: ¦

¦ ¦

¦Are family members familiar with emergency and evacuation plans? ¦

¦ ¦

¦Is this a Non-Smoking House? ¦

¦ ¦

¦Is yard fenced? Is it suitable for children's outdoor play? ¦

¦ ¦

¦Summary assessment of the adequacy of this home and yard for the purpose of ¦

¦providing foster care: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ -S223456 ----------------------Adopt. #10-----+

¦ASSESSMENT OF CHILD CARING SKILLS ¦

¦In the next few screens, there will be sub-topics related to child-caring ¦

¦skills. Within each, there are several fields for rating the family's current ¦

¦abilities. At the end of each sub-topic is an overall assessment in which you ¦

¦describe your assessment rather than using the rating system, or you may use ¦

¦that field to describe your ratings. ¦

¦ ¦

¦1) Protects the child from physical and psychological harm ¦

¦ ¦

¦ a) Maintains a hazard-free home and yard.............: ¦

¦ b) Familiarizes children with emergency and ¦

¦ evacuation plans..................................: ¦

¦ c) Ensures that the child is protected from strangers ¦

¦ and other persons who may harm the child..........: ¦

¦ d) Exercises good judgement in selecting alternate ¦

¦ care for the foster children......................: ¦

¦ e) Addresses special needs in this area..............: ¦

¦ f) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦ ¦

¦Overall assessment in protecting child/ren from harm...: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -S223456 ----------------------Adopt. #11-----+

¦ ¦

¦2) Promotes good physical health, growth, and development ¦

¦ ¦

¦ a) Provides opportunities, encouragement, and good ¦

¦ role models to promote nutrition and exercise.....: ¦

¦ b) Provides appropriate clothing and food............: ¦

¦ c) Initiates and follows through on child's needs for ¦

¦ dental and phyiscal exams and treatments..........: ¦

¦ d) Cooperates with and notifies agency of progress or ¦

¦ problems related to child/ren's physical health...: ¦

¦ e) Submits all documentation related to physical/dental ¦

¦ health and medical treatment in a timely fashion..: ¦

¦ f) Schedules and provides all transportation needed to ¦

¦ attend to child/ren's physical needs..............: ¦

¦ g) Has realistic and practical expectations of ¦

¦ child/ren based on age, abilities, and potential..: ¦

¦ h) Addresses children's special needs in this area...: ¦

¦ i) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦ ¦

¦Overall assessment of the promotion of physical health, etc...: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -S223456 ----------------------Adopt. #12-----+

¦ ¦

¦3) Promotes good social and emotional health, growth, and development ¦

¦ a) Recognizes each child's unique emotional growth ¦

¦ and development need..............................: ¦

¦ b) Provides opportunities, encouragement, and role ¦

¦ models to support open communication, positive ¦

¦ social activities and relationships...............: ¦

¦ c) Initiates and follows through on child/ren's need ¦

¦ for assessment and treatment in this area.........: ¦

¦ d) Cooperates with and notifies agency of progress or ¦

¦ problems related to child/ren's emotional ¦

¦ health/social development.........................: ¦

¦ e) Submits relevant documentation in a timely fashion: ¦

¦ f) Schedules and provides transportation needed to ¦

¦ attend child/ren's emotional and social needs.....: ¦

¦ g) Has realistic and practical expectations of each ¦

¦ child based on age, abilities, and potential......: ¦

¦ h) Addresses child/ren's special needs in this area..: ¦

¦ i) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦Overall assessment of the promotion of social and emotional health...: ¦

¦ ¦

¦TEXT Type=Enter Data = Move in Field = Move in Screen ¦

+ -S223456 ----------------------Adopt. #13-----+

¦ ¦

¦4) Promotes cognitive and educational growth and development ¦

¦ a) Recognizes each child's unique cognitive/intellectual ¦

¦ growth and developmental needs....................: ¦

¦ b) Provides opportunities, encouragement, and role ¦

¦ models to support learning, good study habits, and ¦

¦ intellectual curiosity............................: ¦

¦ c) Initiates and follows through on child/ren's need ¦

¦ for special education assessment and treatment....: ¦

¦ d) Cooperates with and notifies agency and school of ¦

¦ progress or problems related to child/ren's ¦

¦ cognitive and educational growth and development..: ¦

¦ e) Submits relevant documentation in a timely fashion: ¦

¦ f) Schedules and provides transportation needed to ¦

¦ attend child/ren's cognitive and educational needs: ¦

¦ g) Has realistic and practical expectations of each ¦

¦ child based on age, abilities, and potential......: ¦

¦ h) Addresses child/ren's special needs in this area..: ¦

¦ i) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦Overall assessment of the promotion of cognitive and educational growth...: ¦

¦ ¦

¦TEXT Type=Enter Data = Move in Field = Move in Screen ¦

+ -S223456 ----------------------Adopt. #14-----+

¦5) Attitudes Toward Discipline of Children ¦

¦ a) Sets appropriate limits and boundaries...........: ¦

¦ b) Responds consistently to child/ren's appropriate ¦

¦ and inappropriate behaviors......................: ¦

¦ c) Uses appropriate discipline techniques...........: ¦

¦ d) Has realistic and practical expectations of each ¦

¦ child based on age, abilities, and potential......: ¦

¦ e) Uses Behavior Management methods to promote self ¦

¦ control, self esteem and independence in child/ren: ¦

¦ f) Cooperates with and notifies agency of progress or ¦

¦ problems related to child behavior management.....: ¦

¦ g) Addresses child/ren's special needs in this area..: ¦

¦ h) Demonstrates ability, motivation, and positive ¦

¦ attitude in addressing challenges in this area....: ¦

¦ ¦

¦Overall assessment of child discipline: ¦

¦ ¦

¦Child care plan if both parents work: ¦

¦ ¦

¦Who will care for child in the event of death of adoptive parents: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -S223456 ----------------------Adopt. #15-----+

¦ ¦

¦ References ¦

¦ ¦

¦ Summary of Reference 1: ¦

¦ ¦

¦ Summary of Reference 2: ¦

¦ ¦

¦ Summary of Reference 3: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ -S223456 ----------------------Adopt. #16-----+

¦ ¦

¦ The Characteristics of Children Preferred ¦

¦ ¦

¦ Age.....: ¦

¦ ¦

¦ Gender..: ¦

¦ ¦

¦ Race....: Specify: ¦

¦ ¦

¦ Explain.: ¦

¦ ¦

¦ Approved.....: ¦

¦ Approved Date: / / ¦

¦ Approved By..: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ -S223456 ----------------------Adopt. #17-----+

¦ ¦

¦ Agency Recommendations ¦

¦ ¦

¦ Age.....: ¦

¦ Gender..: ¦

¦ Race....: ¦

¦ Capacity: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Child/ren with special needs regarding: ¦

¦ a) Cognitive development/condition.......: ¦

¦ b) Emotional/Social development/condition: ¦

¦ c) Physical development/condition........: ¦

¦ ¦

¦ Overall, describe family evaluation and give recommendations: ¦

¦ ¦

¦ Date Evaluation was given to Adoptive family: / / ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ DSS#: W2343456A Ch. Ev. #1----------+

¦ ADOPTION EVALUATION ¦

¦ ¦

¦Family Number: W2343456 *Wfam AKA..: ¦

¦First Name...: Last Name...: ¦

¦DSS Case #...: W2343456A Soc. Sec.#.........: - - ¦

¦Program......: M.A.#..............: ¦

¦D.O.B........: / / County of Referral : Wayne ¦

¦Race.........: Sex................: ¦

¦Religion.....: ¦

¦School Status prior to placement: School name/grade: ¦

¦ Foch Grade: Sixth grade ¦

¦General Description and Identifying Marks (include height, weight, eye color ¦

¦and hair color) ¦

¦ ¦

¦Adoption Facilitator: Phone: ¦

¦Adoption Supervisor.: Phone: ¦

¦Foster Care Worker..: Phone: ¦

¦DSS Worker..........: Phone: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+----------------------------------------------------------------Mother #1-----+

¦MOTHER: ¦

¦Is mother known: ¦

¦Name........: Deceased?: 0 ¦

¦Relation....: ¦

¦D.O.B.......: / / ¦

¦Race........: ¦

¦Nationality.: Specify..: ¦

¦Religion....: Specify..: ¦

¦Amount of Education: Specify..: ¦

¦Type of Education..: Specify..: ¦

¦Occupation..: ¦

¦Mar. Status.: Specify..: ¦

¦Liv. Arrang.: ¦

¦S.S.N.......: - - ¦

¦Address.....: ¦

¦City/State..: Zip......: ¦

¦Phone ......: Phone #..: ( ) - ¦

¦Height......: Weight.......: Build.....: 0 ¦

¦Skin Color..: 0 Color of Eyes: Hair Color: 0 ¦

¦ ¦

¦General comments about mother: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+-----------------------------------------------------------FATHER #1----------+

¦ FATHER ¦

¦ Is father known: ¦

¦ Name........: Deceased?: 0 ¦

¦ Relation....: ¦

¦ D.O.B.......: / / ¦

¦ Race........: ¦

¦ Nationality.: Specify..: ¦

¦ Religion....: Specify..: ¦

¦ Amount of Education: Specify..: ¦

¦ Type of Education..: Specify..: ¦

¦ Occupation..: ¦

¦ Mar. Status.: Specify..: ¦

¦ Liv. Arrang.: ¦

¦ S.S.N.......: - - ¦

¦ Address.....: ¦

¦ City/State..: Zip......: ¦

¦ Phone ......: Phone #..: ( ) - ¦

¦ Height......: Weight.......: Build.....: 0 ¦

¦ Skin Color..: 0 Color of Eyes: Hair Color: 0 ¦

¦ ¦

¦ General comments about father: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ DSS#: W2343456A Ch. Ev. # 4---------+

¦ Siblings ¦

¦ +-------------------------------------------------------------------------

¦ ¦ Name Age Living Arrangement ¦

¦ ¦------------------------------------------------------------------------

¦ ¦ ¦ ¦

¦ +-------------------------------------------------------------------------

¦ ¦

¦ If permanency plan involves sibling split, indicate why placement together ¦

¦ is not feasible, or not in the child's best interest. ¦

¦ ¦

¦ Describe current and future visitation between siblings. ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

+ DSS#: W2343456A Ch. Ev. # 4---------+

¦ Siblings ¦

¦ +-------------------------------------------------------------------------

¦ ¦ Name Age Living Arrangement ¦

¦ ¦------------------------------------------------------------------------

¦ ¦ ¦

¦ ¦ ¦ ¦

¦+------------------------------------------------------ Family: W2343456 ---+

¦¦Name..........: FIA#..: ¦

¦¦D.O.B.........: / / SSN...: - - ¦

¦¦Relation......: Sex...: ¦

¦¦Living arrang.: ¦-

¦¦ ¦¦

¦¦Address.......: ¦¦

¦¦City/State....: Zip...: ¦¦

¦¦Phone ........: Phone #.: ( ) - ¦¦

¦¦Court ward....: ¦¦

¦¦Comments......: ¦¦

¦¦ ¦¦

¦+----------------------------------------------------------------------------+¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ DSS#: W2343456A Ch. Ev. # 5---------+

¦ Biological Family ¦

¦ (Siblings are added later) ¦

¦ +-------------------------------------------------+ ¦

¦ ¦ Name Age Relation ¦ ¦

¦ ¦-------------------------------------------------¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦ +-------------------------------------------------+ ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

+ DSS#: W2343456A Ch. Ev. # 5---------+

¦ Biological Family ¦

¦ (Siblings are added later) ¦

¦ +-------------------------------------------------+ ¦

¦ ¦ Name Age Relation ¦ ¦

¦ ¦-------------------------------------------------¦ ¦

¦ ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦+-----------------------------------------------Family Number: W2343456 --+¦

¦¦Name.........: SSN......: - - ¦¦

¦¦D.O.B........: / / ¦¦

¦¦Relation.....: ¦¦

¦¦Sex..........: ¦¦

¦¦Address......: ¦¦

¦¦City/State...: Zip......: ¦¦

¦¦ ¦¦

¦¦Phone ...........: Phone #.: ( ) - ¦¦

¦¦Living Arrangment: ¦¦

¦¦Comments.........:

¦¦ ¦¦

¦+----------------------------------------------------------------------------+¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ DSS#: W2343456A Ch. Ev. # 6---------+

¦ ¦

¦ I. Child Contacts ¦

¦ ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦ Date Location Type Worker ¦ ¦

¦ ¦--------------------------------------------------------------------------¦ ¦

¦ ¦ / / ¦ ¦ ¦ ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦ ¦

¦ +--------------------------------------------------------------------------+ ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

*****CHILD CONTACTS SCREENS TO BE ADDED****

+ DSS#: W2343456A Ch. Ev. # 7---------+

¦ II. Events leading to Permanent Wardship ¦

¦ Why was this child removed from its birth family: ¦

¦ (Include how the child came to the attention of the dss/court. ¦

¦ Specify any neglect or physical, sexual or emotional abuse suffered ¦

¦ by the child.) ¦

¦ ¦

¦ Date of Temporary Court Wardship: / / ¦

¦ ¦

¦ Court Appearances ¦

¦ +---------------------------------------+ ¦

¦ ¦ Type of Hearing Date ¦ ¦

¦ ¦---------------------------------------¦ ¦

¦ ¦ ¦ / / ¦ ¦

¦ ¦ ¦ ¦ ¦

¦ +---------------------------------------+ ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+-----------------------------------------------------------------------------++

¦ DESCRIPTION OF COURT HEARING AND RESULTS ¦

¦ ¦

¦Date of Hearing: / / ¦

¦Type of Hearing: ¦

¦Judge/Referee: ¦

¦Court File # : ¦

¦ ¦

¦Children Involved: (List in free text) ¦

¦ ¦

¦OTHER PERSONS INVOLVED: PRESENT?: COMMENTS (names, why not present...) ¦

¦AAG: ¦

¦Attorney for Child/ren ¦

¦Attorney for Parent/s ¦

¦Mother ¦

¦Father/s: ¦

¦Other Agency Workers: ¦

¦Others: ¦

¦ ¦

+ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -:Substract a Day =:Today's Date¦

+-----------------------------------------------------------------------------++

¦ DESCRIPTION OF COURT HEARING AND RESULTS ¦

¦ ¦

¦Brief Summary of What Happened at Hearing: ¦

¦ ¦

¦Outcome: ¦

¦ ¦

¦Requirement of Court: ¦

¦ ¦

¦Next hearing - Date: / / Time: : Type: ¦

¦ ¦

¦Notifications of Next Hearing: (State if notified or not, and any comments) ¦

¦Child/ren: ¦

¦Mother ¦

¦Father(s) ¦

¦Foster Parents: ¦

¦Adoption Services: ¦

¦FIA ¦

¦Other: ¦

+ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev # 8----------+

¦ II. Events leading to Permanent Wardship (continued) ¦

¦ ¦

¦ Efforts made to reunite the family ¦

¦ (The following summarizes the services provided to this child while in ¦

¦ foster care.) ¦

¦ Services To Parents: ¦

¦ ¦

¦ Specify other: ¦

¦ ¦

¦ Services To Children: ¦

¦ ¦

¦ Specify other: ¦

¦ ¦

¦ Comments (about services provided): ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ DSS#: W2343456A Ch. Ev # 9----------+

¦ II. Events leading to Permanent Wardship (continued) ¦

¦ ¦

¦ Efforts made to reunite the family (continued) ¦

¦ ¦

¦ During the time the child was in foster care the permanency plan was ¦

¦ as follows: ¦

¦ ¦

¦ Permanency Planning Goal......: ¦

¦ Return home to................: ¦

¦ Specify type of Custodial Care: ¦

¦ Time Frame (by date)..........: / / ¦

¦ ¦

¦ Comments: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ DSS#: W2343456A Ch. Ev # 10---------+

¦ II. Events leading to Permanent Wardship (continued) ¦

¦ CIRCUMSTANCES OF TERMINATION OF PARENTAL RIGHTS ¦

¦ ¦

¦ Age of parents at time of termination: ¦

¦ ¦

¦ MCI Date: / / ¦

¦ ¦

¦ Length of time between termination of parental rights and adoptive ¦

¦ placement: ¦

¦ ¦

¦ Circumstances of any judicial order terminating the parental rights of ¦

¦ a parent for abuse, neglect, abandonment or other mistreatment of the ¦

¦ child: ¦

¦ ¦

¦ Was termination voluntary or court ordered? ¦

¦ ¦

¦ Did either parent file an appeal to the court's permanent custody ¦

¦ decision? ¦

¦ ¦

¦ If yes, status of appeal: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen ¦

+ DSS#: W2343456A Ch. Ev. # 11--------+

¦ IV. Placement History ¦

¦ ¦

¦ +-------------------------------------------------------------------------+ ¦

¦ ¦ Placement Date In Date Out ¦ ¦

¦ ¦-------------------------------------------------------------------------¦ ¦

¦ ¦ ¦ / / ¦ / / ¦ ¦

¦ ¦ ¦ ¦ ¦ ¦

¦ +-------------------------------------------------------------------------+ ¦

¦ ¦

¦ What was the longest time this child has been in a home? ¦

¦ ¦

¦ How does this child typically behave during moves? ¦

¦ ¦

¦TABLE -+= Update Table = Leave Table ¦

+------------------------------------------------------------------------------+

¦ ¦

¦ Placement name....: ¦

¦ Placement type....: ¦

¦ Address...........: ¦

¦ City/state........: ¦

¦ Zip...............: ¦

¦ Phone.............: ( ) - ¦

¦ ¦

¦ Date in...........: / / ¦

¦ Date out..........: / / ¦

¦ ¦

¦ Reason for removal: ¦

¦ ¦

¦TEXT Enter data=Edit = No Edit; up & down screen

+ DSS#: W2343456A Ch. Ev. # 12--------+

¦ Placement History (continued) ¦

¦ ¦

¦ How has this child dealt with previous relationship losses? ¦

¦ ¦

¦ Describe this child's important past attachments: ¦

¦ ¦

¦ Describe any neglect, or physical, sexual or emotional abuse suffered by ¦

¦ the child while in out of home placement: ¦

¦ ¦

¦ Account of the child's past and existing relationships with any relative, ¦

¦ foster parent, or other individual with whom the child has lived or visited ¦

¦ on a regular basis: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #13---------+

¦ ¦

¦ Current Placement ¦

¦ ¦

¦ Name......: ¦

¦ Address...: ¦

¦ City/State: ¦

¦ Zip.......: ¦

¦ Phone.....: ( ) - ¦

¦ ¦

¦ Date In...: / / ¦

¦ ¦

¦ Adjustment to placement: ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦ Relationship with present care givers: 0 ¦

¦ ¦

¦ Explain: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ DSS#: W2343456A Ch. Ev. #14---------+

¦ V. Family History - Birth Parent History And Functioning ¦

¦ Mother ¦

¦ ¦

¦ Mother's medical history: ¦

¦ ¦

¦ Mother's psychological history: ¦

¦ ¦

¦ Summary of findings of medical, psychological or psychiatric evaluations ¦

¦ at the time of placement: ¦

¦ ¦

¦ Were there any patterns or experiences of the mother that may have led to ¦

¦ the abuse or neglect of the adoptive child: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ DSS#: W2343456A Ch. Ev. #15---------+

¦ V. Family History - Birth Parent History And Functioning ¦

¦ Mother ¦

¦ ¦

¦ Previous Marriages ¦

¦ ¦

¦ Length of mother's marriage at the time the child became a permanent ¦

¦ court ward (if this marriage was not to the biological father, ¦

¦ please indicate.): ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #16---------+

¦ V. Family History - Birth Parent History And Functioning ¦

¦ Father ¦

¦ ¦

¦ Father's medical history: ¦

¦ ¦

¦ Father's psychological history: ¦

¦ ¦

¦ Summary of findings of medical, psychological or psychiatric evaluations ¦

¦ at the time of placement: ¦

¦ ¦

¦ Were there any patterns or experiences of the father that may have led to ¦

¦ the abuse or neglect of the adoptive child: ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ DSS#: W2343456A Ch. Ev. #17---------+

¦ V. Family History - Birth Parent History And Functioning ¦

¦ Father ¦

¦ ¦

¦ Previous Marriages ¦

¦ ¦

¦ Length of Father's marriage at the time the child became a permanent ¦

¦ court ward (if this marriage was not to the biological mother, ¦

¦ please indicate.): ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #18---------+

¦ V. Family History - Birth Parent History And Functioning ¦

¦ Mother and her EXTENDED FAMILY ¦

¦ 1) Medical (Select all that apply) ¦

¦ ¦

¦ 2) Psychological: ¦

¦ ¦

¦ 3) Describe any further information on levels of educational, occupational, ¦

¦ professional, athletic or artistic achievement of mother or any members ¦

¦ of her family. ¦

¦ ¦

¦ 4) Describe what is known about hobbies, special interests, school ¦

¦ activities and childhood of mother or her extended family. ¦

¦ ¦

¦ 5) Describe what is known of mother's strengths or personality and the ¦

¦ strengths of her extended family. ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ DSS#: W2343456A Ch. Ev. #19---------+

¦ V. Family History - Birth Parent History And Functioning ¦

¦ Father and his EXTENDED FAMILY ¦

¦ 1) Medical (Select all that apply) ¦

¦ ¦

¦ 2) Psychological: ¦

¦ ¦

¦ 3) Describe any further information on levels of educational, occupational, ¦

¦ professional, athletic or artistic achievement of father or any members ¦

¦ of his family. ¦

¦ ¦

¦ 4) Describe what is known about hobbies, special interests, school ¦

¦ activities and childhood of father or his extended family. ¦

¦ ¦

¦ 5) Describe what is known of father's strengths or personality and the ¦

¦ strengths of his extended family. ¦

¦ ¦

¦LIST (multiple choice) -+= Edit = Up & Down Screen ¦

+ DSS#: W2343456A Ch. Ev. #20---------+

¦ VI. Medical and Developmental History: ¦

¦ ¦

¦ Birth History ¦

¦ Date....: / / ¦

¦ Time....: ¦

¦ Hospital: ¦

¦ City....: ¦

¦ County..: ¦

¦ State (Use two-letter Postal code abbreviation): ¦

¦ ¦

¦ Newborn health appraisal: ¦

¦ ¦

¦ Was this child born substance addicted or exposed: 0 Addicted ¦

¦ Exposed ¦

¦ Suspected Exposure¦

¦ unknown ¦

¦ Provide documentation for addiction or exposure: ¦

¦ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -: Substract a Day =:Today's Date¦

+ DSS#: W2343456A Ch. Ev. #20---------+

¦ VI. Medical and Developmental History: ¦

¦ ¦

¦ Birth History ¦

¦ Date....: / / ¦

¦ Time....: ¦

¦ Hospital: ¦

¦ City....: ¦

¦ County..: ¦

¦ State (Use two-letter Postal code abbreviation): ¦

¦ ¦

¦ Newborn health appraisal: ¦

¦ ¦

¦ Was this child born substance addicted or exposed: 0 Addicted ¦

¦ Exposed ¦

¦ Suspected Exposure¦

¦ unknown ¦

¦ Provide documentation for addiction or exposure: ¦

¦ ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -:Subtract a Day =:Today's Date¦

******IMMUNIZATION SCREEN TO FOLLOW *******

+------------------------------------------------------------------------------+

¦ CHILD'S DISABILITIES ¦

¦Has this child been CLINICALLY diagnosed as having a ¦

¦disability(ies)?...................: No As Of: 01/23/97 ¦

¦For each of the following disabilities: ¦

¦ YES indicates that a qualified professional has clinically diagnosed the ¦

¦ child has having at least one of the disabilities listed below. ¦

¦ NO indicates that a qualified professional has conducted a clinical ass- ¦

¦ essment of the child and has determined that the child has no disabilities. ¦

¦ Not yet determined indicates that a clinical assessment of the child by ¦

¦ a qualified professional has not been conducted. ¦

¦Mental Retardation......: No ¦

¦ Explain: ¦

¦Visually Impaired.......: No ¦

¦ Explain: ¦

¦Hearing Impaired........: No ¦

¦ Explain: ¦

¦Physically Disabled.....: No ¦

¦ Explain: ¦

¦Emotionally Disturbed...: No ¦

¦ Explain: ¦

¦Other Medical Conditions: No ¦

¦ Explain: ¦

¦Comments: ¦

¦DATE Enter Date:Type F9:Calendar +:Add a Day -:Subtract a Day =:Today's Date¦

+ DSS#: W2343456A Ch. Ev. #23---------+

¦ VI. Medical and developmental History: ¦

¦ Developmental Milestones: ¦

¦ ¦

¦ Indicate developmental milestones of the child. Include specifically ¦

¦ information with regards to the child's motor skills and age he or she ¦

¦ began walking; verbal skills and age he or she began talking; hygiene ¦

¦ habits and toilet training process including age. Discuss any known ¦

¦ problems in attaining age normative milestones. ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #24---------+

¦ VII. Sexual Development ¦

¦ Sexual development is not reported specifically in any one section of the ¦

¦ foster care record. However, information may be provided in the USP ¦

¦ Emotional/Psychological Progress section and in the Difficulty of Care ¦

¦ section. After reading foster care records it is therefore important to ¦

¦ interview all potentially relevant others to obtain information for this ¦

¦ section. ¦

¦ ¦

¦ Child's age-appropriate level of understanding of sexual behavior: ¦

¦ ¦

¦ Child's age-appropriate knowledge of human sexuality and development ¦

¦ (e.g. changes due to puberty, conception and pregnancy, STD's and risky ¦

¦ sexual behavior): ¦

¦ ¦

¦ Any sexual experiences: ¦

¦ ¦

¦ If age-appropriate, any sexual identity issues: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #25---------+

¦ VII. Sexual Development (continued) ¦

¦ Any known or suspected sexual abuse: ¦

¦ ¦

¦ Include who and what happened (for known or suspected). ¦

¦ ¦

¦ Describe efforts to obtain information, sources and findings. ¦

¦ ¦

¦ Any current or past history of sexual acting out: ¦

¦ ¦

¦ Describe the acting-out behavior, and if there were any victims involved. ¦

¦ ¦

¦ Describe efforts to obtain information, sources and findings. ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ DSS#: W2343456A Ch. Ev. #26---------+

¦ VII.B. General Functioning ¦

¦ Is this child age appropriate in self-care: ¦

¦ ¦

¦ Describe eating and diet habits: ¦

¦ ¦

¦ Describe sleep habits: ¦

¦ ¦

¦ Describe personal hygiene: ¦

¦ ¦

¦ Any further comments on age-appropriateness: ¦

¦ ¦

¦ Does this child respond better to a rigid or flexible routine? ¦

¦ (Please note both your assessment and sources of information) ¦

¦ ¦

¦ What suggestions does the current child's caregiver have for future adoptive ¦

¦ parents? ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ DSS#: W2343456A Ch. Ev. #27---------+

¦VIII. Academic Functioning ¦

¦ Child's Educational history ¦

¦ Sources of information for child's educational history include the IIS, ¦

¦ agency, school or counselor's records. It is important to seek out ¦

¦ sources such as the child, foster parent, parent, current teacher or other ¦

¦ school personnel to obtain a more full picture, as school records may be ¦

¦ incomplete or misplaced. In responding to each of the following questions, ¦

¦ be sure to note source and date of all information. ¦

¦ List current and past schools attended, including dates or grades as known: ¦

¦ ¦

¦ Special Education: ¦

¦ ¦

¦ Describe efforts to obtain information, sources of information and ¦

¦ any additional findings relating to special education or any ¦

¦ other academic testing. ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #28---------+

¦VIII. Academic Functioning (continued) ¦

¦ Child's Educational history (continued) ¦

¦ Document dates and results for standardized academic tests such as the ¦

¦ MEAP, CAT or Iowa Tests. Testing is provided at a set sequence. Results ¦

¦ can be obtained from child's school records. ¦

¦ ¦

¦ Document current academic year's school grades and summarize typical ¦

¦ school grades from previous years. Note if there has been any rise or ¦

¦ drop in grades or level of course work. ¦

¦ ¦

¦ Describe any behavior problems in school or school phobia. ¦

¦ ¦

¦ Child's Academic Strengths and Weaknesses ¦

¦ Describe this child's academic strengths. ¦

¦ ¦

¦ Describe this child's academic weaknesses. ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #29---------+

¦VIII. Academic Functioning (continued) ¦

¦ Child's Educational Plan ¦

¦ ¦

¦ Document likely educational needs for this child in the future: ¦

¦ ¦

¦ Describe what adoptive parents should do to facilitate this plan: ¦

¦ ¦

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+ DSS#: W2343456A Ch. Ev. #30 --------+

¦IX. Emotional Functioning ¦

¦ ¦

¦The goal of this section is to capture the child's emotional history and ¦

¦assess the child's current emotional needs. ¦

¦ ¦

¦CURRENT AND FUTURE IMPACT OF CRITICAL EVENTS ¦

¦Summarize critical events such as those leading to permanent wardship, ¦

¦events in the child's placement history, events in the child's relationship ¦

¦with biological parents. Describe how the child reacted at the time and ¦

¦how these experience impact on current functioning and expected future ¦

¦coping abilities. Outline what an adoptive family could expect in the future. ¦

¦As applicable, be sure to describe early experience in the birth family, ¦

¦violence, abuse or neglect, number and types of moves. In assessing the ¦

¦child's reaction take in to account self-image, depression, withdrawal, ¦

¦agression and "acting out" or regression. ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #31---------+

¦IX. Emotional Functioning (continued) ¦

¦ASSESSMENT OF APPROPRIATE PARENTING ¦

¦Based on this child's past experiences and developmental history describe ¦

¦this child's needs with regard to parenting. In particular outline the type ¦

¦of affection, amount and type of attention, type of discipline, need for ¦

¦relational closeness or distance, need for supervision of hygiene and ¦

¦bedtime preparation and nighttime supervision for children with night fears. ¦

¦ ¦

¦CHILD'S ATTACHMENT RELATIONSHIPS ¦

¦Assess this child's attachment history. Describe the quality of this child's ¦

¦relationships with adults, peers and others. Note any known warm or close ¦

¦attachments the child has formed. Include specific information about any ¦

¦special friendships, connections with adults or with school, and what can ¦

¦be done to maintain them. Is there evidence the child has difficulty ¦

¦with attachment? (Evidence of difficulties could be inability to distinguish ¦

¦right from wrong, or seeming lack of conscience as well as more concrete ¦

¦indicators such as multiple moves in infancy and early toddlerhood). ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #32---------+

¦IX. Emotional Functioning (continued) ¦

¦CHILD'S SELF-ESTEEM AND IDENTITY ¦

¦Assess how this child feels about him- or her-self. Include the level of ¦

¦self-esteem and this child's expectations for what he or she will be like ¦

¦in the coming years: ¦

¦ ¦

¦HISTORY OF THERAPY ¦

¦Has the child been in therapy: ¦

¦ ¦

¦Date in: / / Date out: / / ¦

¦ ¦

¦Name, Address and phone # of last therapist: ¦

¦ ¦

¦Any medication, include type and dosage: ¦

¦ ¦

¦Any testing, include type and findings: ¦

¦ ¦

¦Summarize the psychiatric history: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #33---------+

¦X. Attitude Toward And Readiness For Adoption ¦

¦ ¦

¦This section focuses on assessing the child's understanding of adoption, ¦

¦including his or her attitude about losing bonds with the biological family, ¦

¦being freed for adoption and the process of adoption itself. In order to ¦

¦make this assessment, the child should be interviewed as is developmentally ¦

¦appropriate, and additional sources of information such as adults in ¦

¦the child's life, observation of the child and written records from foster ¦

¦care or counseling should be utilized. In response to each question it ¦

¦is important to indicate sources of information and dates information was ¦

¦collected. ¦

¦ ¦

¦Describe this child's understanding of why he or she became a PCW? ¦

¦ ¦

¦What are the child's stated feelings about becoming a permanent court ward, ¦

¦and adoption? ¦

¦ ¦

¦Worker's assessment of child's feelings about adoption: ¦

¦ ¦

¦FREE TEXT (memo) -+= Edit = No Edit; up & down screen F7= Zoom In

+ DSS#: W2343456A Ch. Ev. #34---------+

¦X. Attitude Toward And Readiness For Adoption (continued) ¦

¦ ¦

¦Remember that this section focuses on assessing the child's understanding of ¦

¦adoption,including his or her attitude about losing bonds with the biological ¦

¦family, being freed for adoption and the process of adoption itself. In order ¦

¦to make this assessment, the child should be interviewed as is developmentally¦

¦appropriate, and additional sources of information such as adults in ¦

¦the child's life, observation of the child and written records from foster ¦

¦care or counseling should be utilized. In response to each question it ¦

¦is important to indicate sources of information and dates information was ¦

¦collected. ¦

¦ ¦

¦Describe this child's understanding of adoption? ¦

¦ ¦

¦What are the issues that must be addressed prior to, and during the adoption ¦

¦preparation process? ¦

¦ ¦

¦What is this child's ability to form an attachment relationship to new ¦

¦parents? ¦

¦ ¦

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+ DSS#: W2343456A Ch. Ev. #35---------+

¦XI. Best Interest Criteria ¦

¦SPECIAL PHYSICAL AND EMOTIONAL NEEDS. ¦

¦Utilizing information gathered throughout this report, summarize briefly ¦

¦the child's needs and requirements in each of the following domains: ¦

¦ ¦

¦Emotional needs: ¦

¦ ¦

¦Describe emotional needs, include intensity of total care, need for close ¦

¦supervision or firm limits: ¦

¦ ¦

¦Physical needs: ¦

¦ ¦

¦Describe physical needs: ¦

¦ ¦

¦Educational needs: ¦

¦ ¦

¦Describe educational needs: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ DSS#: W2343456A Ch. Ev. #36---------+

¦XI. Best Interest Criteria (continued) ¦

¦ ¦

¦Placement with Siblings. ¦

¦Utilizing information gathered from family history (sib screen 1 and 2), ¦

¦summarize briefly whether this child will be placed with siblings, reasons ¦

¦if this is not the case, and plans for future contact. ¦

¦ ¦

¦Placement with Relatives. ¦

¦Utilizing information from the foster care files and specific contacts with ¦

¦relatives or other sources, indicate whether there is a relative that is ¦

¦interested and willing to adopt this child.: ¦

¦ ¦

¦Document efforts to find and notify relatives or significant others who ¦

¦might be interested and willing to adopt this child. ¦

¦ ¦

¦If a relative is interested and willing, state what consideration will ¦

¦be given them.: ¦

¦ ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ DSS#: W2343456A Ch. Ev. #37---------+

¦XI. Best Interest Criteria (continued) ¦

¦MAINTAINING CONTINUITY OF CURRENT PLACEMENT. ¦

¦Utilizing information gathered from placement history ( screen 1 and 3) ¦

¦and interaction with child and current caregivers, document the following: ¦

¦ ¦

¦To what extent is it important for this child to maintain his or her ¦

¦relationship with the current caregivers: ¦

¦ ¦

¦To what extent is it feasible for this child to maintain his or her ¦

¦relationship with the current caregivers: ¦

¦ ¦

¦Document when the current caregiver was notified that the child was freed ¦

¦for adoption. ¦

¦ ¦

¦Does the current caregiver wish to adopt this child? ¦

¦ If no, to what extent is the caregiver willing to cooperate with the ¦

¦ adoption plan.: ¦

¦ ¦

¦ If no, to what extent is the caregiver open to future ongoing contact ¦

¦ with the child: ¦

¦ ¦

¦Describe the current caregiver's feelings about adoption, the adoption plan ¦

¦and future contact. ¦

¦LIST (single choice) -+= Edit Input Code 0= Empty Field =Up & Down Screen¦

+ DSS#: W2343456A Ch. Ev. #38---------+

¦XI. Best Interest Criteria (continued) ¦

¦ ¦

¦RACIAL IDENTITY FACTOR. ¦

¦Assessment of racial identity should involve discussion with the child ¦

¦at a level that is age-appropriate for the child. ¦

¦ ¦

¦State the child's race: ¦

¦ Specify: ¦

¦Hispanic origin.......: ¦

¦ ¦

¦Child's perceived racial identity, if any: ¦

¦ Specify: ¦

¦Perceived hispanic origin................: ¦

¦ ¦

¦Child's racial preference for adoptive parents, if any: ¦

¦ ¦

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+ DSS#: W2343456A Ch. Ev. #39---------+

¦XI. Best Interest Criteria (continued) ¦

¦ ¦

¦RACIAL IDENTITY FACTOR (continued). ¦

¦Assessment of racial identity should involve discussion with the child ¦

¦at a level that is age-appropriate for the child. ¦

¦ ¦

¦Child's knowledge of, and comfort with various racial groups: ¦

¦ ¦

¦Type of racial placement that would be in the child's best interest: ¦

¦ ¦

¦Describe best-interest placement type: ¦

¦ ¦

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+ DSS#: W2343456A Ch. Ev. #40---------+

¦XI. Best Interest Criteria (continued) ¦

¦ ¦

¦CHILD'S RELIGIOUS PREFERENCE ¦

¦Utilizing information gathered from foster care, and discussion with the ¦

¦child, current caregiver and any relevant others, document the following: ¦

¦Child's religious preference: ¦

¦ ¦

¦Does the child attend any religious facility or institution (e.g. specific ¦

¦church, day school or camp, religious fellowship): ¦

¦ ¦

¦What plans, if any, are there to continue this affiliation: ¦

¦ ¦

¦Child's Wishes ¦

¦Is there a specific person the child wishes to have as an ¦

¦adoptive parent: ¦

¦Is this specific person interested and willing to adopt? ¦

¦ ¦

¦State the child's wishes with regard to adoptive placement: ¦

¦ ¦

¦Describe other factors particular to this child that have not already been ¦

¦mentioned elsewhere in the report (e.g. the child's likes, dislikes or ¦

¦fears): ¦

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+ DSS#: W2343456A Ch. Ev. #41---------+

¦XII. Recommendation ¦

¦ ¦

¦Is adoption the appropriate plan? ¦

¦ ¦

¦ If no, why not? ¦

¦ ¦

¦ If no, what is the appropriate permanency plan: ¦

¦ ¦

¦If yes, provide a clear and specific recommendation as to the type of ¦

¦adoptive family that will best suit this child: ¦

¦ ¦

¦If yes, what training will a family need to parent this child: ¦

¦ ¦

¦What are the rewards and challenges of parenting this child: ¦

¦ ¦

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