ࡱ> TWKLMNOPQRSwCf@ 73^bjbjצצ nq0 0 0 0 xh l& /(///0rE2 3d-444444$cRXY Q400Q4Q4X0 0 //DDDQ40 8/ /-DQ4-DDjv[h  !^/# o̻c8u]2`9Ǭ0]zEy;0Ed!^0 0 0 0 E !^m3"3D33m3m3m3XX1BD1CHILDREN S FOSTER CARERESIDENTIAL INITIAL SERVICE PLAN (10 - 13 yrs)Michigan Department of Human Services  MACROBUTTON [sjc] "Click Here to Enter Agency Name and Address"  Date of Report: FORMTEXT      Report Period: FORMTEXT       Through  FORMTEXT      I.Identifying Information A. Child: Enter the child s name, date of birth, case number, the facility name, specific program name and address of the facility, date entered out of home placement, current placement type, date of current placement, and the next anticipated placement of the child and the anticipated placement date as specified by DHS. Indicate the permanency planning goal (as specified by DHS), sex, and race of the child.Name:Date of Birth:Case Number: FORMTEXT       FORMTEXT       FORMTEXT      Child s Address:Date Entered Care: FORMTEXT       FORMTEXT      Current Placement Type:Date of Current Placement:Anticipated Next Placement Type:Date Anticipated Next Placement: FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMTEXT      Perm. Plan GoalMichigan Goal FORMDROPDOWN  FORMDROPDOWN  Sex: Race:Check if Ethnicity is Hispanic/Latino: FORMDROPDOWN  FORMDROPDOWN  FORMCHECKBOX Parent (Caretaker) Name(s): For each adult parent or caretaker, non-parent adult with a significant relationship or who is a potential placement, provide the name and relationship to child, the address and telephone number, date of birth, sex and race of the person. Name:Relationship:Date of Birth: FORMTEXT       FORMTEXT       FORMTEXT      Parent s Current Address:Telephone: FORMTEXT       FORMTEXT      Sex:Race:Check if Ethnicity is Hispanic / Latino: FORMDROPDOWN  FORMDROPDOWN  FORMCHECKBOX Commitment or Referral Information: DHS Local Office Name:DHS Worker Name:DHS CDUL No s.:DHS Worker Telephone: FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT    FORMTEXT      POS Agency Name:POS Agency Worker Name:POS Agency Telephone: FORMTEXT       FORMTEXT       FORMTEXT      Court ID Number:Judge s Name:Judge s Telephone: FORMTEXT       FORMTEXT       FORMTEXT      II.Legal Status Add the information in this section as requested. Initial Wardship is TCW or MCI Ward as specified by the DHS worker. In the space following this section, add any pertinent narrative concerning court requirements.Initial Wardship Type and DateLast Court Type and Date FORMTEXT       FORMTEXT      Current Wardship Type and DateNext Court Type and Date FORMTEXT       FORMTEXT        MACROBUTTON [1] "Click Here and Type"   III.Social Work Contacts List date, person contacted, role/position, type of contact (telephone, in person, home visit, office visit, etc.) for each contact, attempted contact, and scheduled, but unkept, appointment. If desired, provide a brief narrative statement of the specific reason for the contact. Limit the narrative to one sentence.  MACROBUTTON [1] "Click Here and Type"   IV.Child AssessmentA.Child History, Response to Placement and Services Provided, Offered or Planned and Anticipated Next Placement: Describe for the child addressed in this report; emotional and physical development, past experiences and, problems including information about any known prior CPS history and past placements of the child and/or siblings (list all siblings). Include a physical description of the child, hobbies, likes and dislikes, etc. Describe the reasons the child was placed in residential care. Describe the Childs response to the current placement. Describe the services provided, offered to or planned for the child, parent(s), guardian, or custodian, and non-parent adult including past and present placements, potential placements, if applicable, to return the child home or move to less restrictive placement. List dates of individual/group counseling/therapy. List primary treatment goals. Describe progress achieved during this report period. Include all efforts made by DHS or the Child Placing Agency with family and court responsibility. Indicate the anticipated next placement and the projected time frame for the placement.  MACROBUTTON [1] "Click Here and Type"   B.Child Needs and Strengths AssessmentScore only one child on this assessment. Address and explain each individual item scored as strength or need on the Child Assessment of Needs and Strengths for each child in the space provided following each item. Provide the reasons that each item is scored as a strength or need. If there are significant discrepancies between facility scoring of any need item and the worker with primary family responsibility, it must be identified and resolved through a conference with the family worker. Item C1.Medical/Physical Was there prenatal drug/alcohol exposure? Y N U/K FORMDROPDOWN Is there a need for prenatal care? Y N U/K FORMDROPDOWN a. Good Health +5b. Adequate health 0c. Situational concerns -2d. Impaired health -3e. Severely impaired health -5f. Unable to score US FORMDROPDOWN C1. MEDICAL/PHYSICAL HEALTH Was there prenatal drug/alcohol exposure? Answer yes, no, or unknown. Is there a need for prenatal care? Yes, No or unknown. A. Good health. Child has no known health care needs; child receives routine preventive and medical/dental/vision care, immunizations, health screenings, and hygiene care. If child resided in a high risk environment for lead exposure, the child has received a lead exposure screening. Child has knowledge of puberty and is not experiencing any related medical problems. B. Adequate health. Child has no unmet health care needs or has minor health problems (ex. allergy shots/medications, etc.) that can be addressed with routine intervention; age-appropriate immunizations and annual medical exams and required health screenings are current. Child has some knowledge of puberty and is experiencing minor or no related medical problems. C. Situational concern. Child has a special condition(s)/health concern(s) (ex. lice, cold/flu, ear infections, bone fracture, etc.) that may require temporary (anticipated not to exceed 90 days) medical treatment (ex. follow-up with medical personnel, administering of prescription or over-the-counter medications, etc.); and/or child has not received required immunizations or health screenings (including lead exposure if child resided in a high risk environment for lead exposure). D. Impaired health. Child has a medical condition(s) that may impair daily functioning (ex. fragile asthmatic, eczema, allergies, etc.) and requires ongoing interventions. This may include effects of prenatal drug/alcohol exposure and/or effects of lead exposure. Child has limited knowledge of puberty and/or is experiencing some related medical problems. E. Severely impaired health. Child has a serious, chronic, or acute health condition(s), (ex. diabetes, cerebral palsy, or physical disability, pronounced effects of lead exposure, etc.) that severely impairs functioning and requires ongoing intervention(s). Child has no knowledge of puberty and/or is experiencing significant related medical problems..  MACROBUTTON [1] "Click Here and Type"  ItemC2.Mental Health and Well-Beinga. Healthy emotional behavior/coping skills +5b. Appropriate emotional behavior/coping skills 0c. Situational concern -2d. Limited emotional behavior/coping skills -3e. Severely limited emotional behavior/coping skills -5f. Unable to score US FORMDROPDOWN Item C2 MENTAL HEALTH AND WELL-BEING A. Healthy emotional behavior/coping skills. Child consistently exhibits an age-appropriate range of emotional behaviors; child displays strong age-appropriate coping skills in dealing with disappointment, anger, grief, stress, and daily challenges in home, school, and community; child is also able to identify the need for, seeks, and accepts guidance; child has a positive and hopeful attitude and readily adjusts to new situations. B. Appropriate emotional behavior/coping skills. Child generally exhibits an age-appropriate range of emotional behaviors. Child displays developmentally appropriate emotional coping responses that do not, or minimally interfere with, school, family, or community functioning. Child has age-appropriate ability to cope with a range of emotions and social environments. Child has ability to adjust to new situations. C. Situational concern. Child may demonstrate some symptoms reflecting situational sadness, anxiety, aggression, or withdrawal; maintains situationally-appropriate emotional control. This does not include short-term, adverse reactions to parental visitation, but could include response to initial placement or re-placement (ex. temper tantrums, nightmares, loss of appetite, bedwetting, etc.). D. Limited emotional behavior/coping skills. Child has some difficulty dealing with daily stresses, crises, or problems which interfere with family, school, and/or community functioning. Problems may include but are not limited to, withdrawal from social interaction, flat affect, changes in sleeping or eating patterns, increased aggression, unusually low frustration/tolerance, frequent threats to run away, etc. E. Severely limited emotional behavior/coping skills. Child has consistent difficulty in dealing with daily stresses, crises, or problems which severely impair family, school, and/or community functioning. Child may have diagnosed psychiatric disturbance and may demonstrate severe behavior such as fire setting, suicidal behavior, violence toward people and/or animals, self mutilation, runs away from placement, etc. .  MACROBUTTON [2] "Click Here and Type"  Item C3.Family and Kin/Fictive Kin Relationships/Attachmentsa. Nurturing/Supportive Relationships/Attachment +5b. Appropriate relationships/attachments 0c. Situational concern -2d. Limited Relationships/Attachments -3e. Severely Limited Relationships/Attachments -5f. Unable to score US FORMDROPDOWN Item C3 FAMILY AND KIN/FICTIVE KIN RELATIONSHIPS/ATTACHMENTS Score the childs interaction with his/her family (those individuals the child is related to or views as family). For children in placement, base assessment on visits and other contact such as telephone contact or letters. A. Nurturing/supportive relationships/attachments. Child has positive interactions with and exhibits strong attachments to family, kin, fictive kin, and/or caregiver. Child has sense of belonging with family. B. Appropriate relationships/attachments. Child has positive interactions with and exhibits appropriate attachments to family, kin, fictive kin, and/or caregiver despite some minor conflicts. C. Situational concern. Child experiences temporary strain in interaction with family members. Child may be temporarily angry with the family and/or lacks desire for family interaction (ex. visitation, telephone contact, threaten truancy if visit occurs, refuses to participate in family therapy, etc.). D. Limited relationships/attachments. Child does not have positive interactions with family, does not exhibit appropriate attachments to family, kin, fictive kin, and/or caregiver. Child does not have a sense of belonging with family. E. Severely limited or no relationships/attachments. Child has no interactions or has non-supportive, destructive interactions with family, and exhibits negative attachments to family, kin, fictive kin, and/or caregiver.  MACROBUTTON [2] "Click Here and Type"  ItemC4.EducationDoes child have a special education plan? Y N FORMDROPDOWN Does child need an assessment for special education? Y N FORMDROPDOWN a. Exceptional academic achievement +4b. Adequate achievement 0c. Situational concern -1d. Minor difficulty -2e. Major/chronic difficulty -4f. Unable to score US FORMDROPDOWN Item C4 EDUCATION Does child have a special education plan? Answer yes or no. Does child need assessment for special education? Answer yes or no. A. Exceptional academic achievement. Child is working above grade level and/or is exceeding the expectations of the childs specific educational plan. B. Adequate achievement. Child is working at grade level and/or is meeting expectations of the childs specific educational plan. C. Situational concern. Child may demonstrate some school difficulties (ex., decreased concentration in the classroom, acting-out behavior, regression in academic performance, etc.) that appear temporary in nature. D. Minor difficulty. Child is working below grade level in at least one, but not more than half of subject areas, indicating that the current educational plan may need modification. The child may be exhibiting some truancy or school behavioral problems. E. Major/chronic difficulty. Child is working below grade level in more than half of subject areas and/or is not meeting the goals of the existing educational plan, indicating that the current plan needs modification, or the child needs a specific educational plan and does not have one in place. Child is frequently truant. Score this item for a child who is legally required to attend school and is not attending, or who has been expelled/excluded from school.  MACROBUTTON [2] "Click Here and Type"  ItemC5.Substance Use (Substances include alcohol, tobacco, and other drugs)a. No substance use +1b. Past experimentation 0c. Situational concern -2d. Periodic substance use -3e. Frequent substance use -4f. Unable to score US FORMDROPDOWN Item C5 SUBSTANCE USE (Substances include alcohol, tobacco, and other drugs) A. No substance use. Child does not use alcohol, drugs, or other substances and is age-appropriately aware of consequences of use. Child is not in peer relationships/social activities involving alcohol and/or other drugs and/or chooses not to use despite peer-pressured opportunities to use. No demonstrated history or current problems related to substance use. B. Past experimentation. Child may have past experience with alcohol and/or other drugs but there is no indication of sustained use. C. Situational concern. Child may have an isolated incident or experience with alcohol, tobacco, or other drugs that is not recurring. D. Periodic substance use. Childs alcohol and/or other drug use has resulted in problematic behavior at home, school, and/or in the community. Use may include multiple drugs. Child may be involved in peer relationships/social activities involving alcohol, drugs, and other substances. E. Frequent substance use. Childs frequent alcohol, drug, or other substance usage results in severe behavior disturbances at home, school, and/or in the community. Child may require medical intervention to detoxify  MACROBUTTON [2] "Click Here and Type"  ItemC6.Sexual BehaviorHas child been sexually abused? Y N U/K FORMDROPDOWN Does child demonstrate sexually inappropriate behavior? Y N U/K FORMDROPDOWN a. Healthy sexual adjustment/responsible behavior +1b. Appropriate sexual adjustment/behavior 0c. Situational concern -2d. Compromised sexual adjustment/behavior -3e. Severely compromised sexual adjustment/reckless behavior -4f. Unable to score US FORMDROPDOWN Item C6 SEXUAL BEHAVIOR Has child been sexually abused? Answer yes, no, or unknown. Does child demonstrate sexually inappropriate behavior? Answer yes, no, or unknown. Examples may include, but are not limited to, a child who engages in persistent self-stimulation, chronically acts-out toward others in sexually inappropriate ways, or engages in sexual contact with others. A. Healthy sexual adjustment/responsible behavior. Child displays no signs or history of sexual abuse or exploitation. Child exhibits developmentally appropriate sexual awareness and interest. Child has accurate knowledge of reproduction. B. Appropriate sexual adjustment/behavior. Child does not show any indications of their past sexual abuse and responds to treatment/intervention. Child may participate in age-appropriate sexual behavior or may show age-appropriate interest in sexuality. Child has some knowledge of reproduction. C. Situational concern. Child exhibits a heightened interest/awareness of sexuality that may be a response to a current change in situation or incident (ex. traumatic event, initial or change in placement, too much stimulus in environment, etc.). D. Compromised sexual adjustment/behavior. Child is displaying inappropriate behavior due to known or suspected sexual abuse or exploitation. Behaviors may include more sexualized behaviors than same aged children, preoccupation with sexual themes, increased masturbation, and/or simulating sex acts. Child participates in sexual activities. E. Severely compromised sexual adjustment/reckless behavior. Child exhibits severe sexual dysfunction. Indicators may include perpetrating behaviors (involving force or coercion), severe sexual preoccupation, compulsive masturbation and sexual victimization. Child engages in high risk sexual behaviors and may become involved in illegal sexual activity such as prostitution or pornography.  MACROBUTTON [2] "Click Here and Type"  Rate the child according to their current level of functioning.ItemC7.Life Skillsa. Appropriate life skills +3b. Adequate life skills 0c. Situational concern -1d. Limited life skills -2e. Severely limited life skills -3f. Unable to score US FORMDROPDOWN Item C7 LIFE SKILLS A.  SEQ CHAPTER \h \r 1Appropriate life skills. Child consistently demonstrates age-appropriate ability to feed, bathe, and groom him/herself; the child manages daily routine without intervention. B.  SEQ CHAPTER \h \r 1Adequate life skills. Child demonstrates some age-appropriate ability to feed, bathe, and groom him/herself. Child may need occasional intervention with daily routine. C. Situational concern. Child may need intervention in daily routine due to temporary situation, such as physical injury. D.  SEQ CHAPTER \h \r 1Limited life skills. Child does not consistently demonstrate age-appropriate ability to feed, bathe, and groom him/herself. Child requires intervention with daily routines. E.  SEQ CHAPTER \h \r 1Severely limited life skills. Child rarely demonstrates an age-appropriate ability to feed, bathe, and groom him/herself. Child requires extensive or constant intervention and supervision to manage daily routine  MACROBUTTON [2] "Click Here and Type"  ItemC8.Peer/Adult Social Relationships (Non-Family)a. Strong social relationships +3b. Adequate social relationships 0c. Situational concern -1d. Limited social relationships -2e. Severely limited social relationships -3f. Unable to score US FORMDROPDOWN Item C8 PEER/ADULT SOCIAL RELATIONSHIPS (NON-FAMILY) A. Strong social relationships. Child routinely interacts with social groups having positive support and influence, models responsible behavior, participates in constructive age-appropriate activities. Child is actively engaged with a positive support network and has some close, positive relationships with adults. Child displays age-appropriate solutions to social conflict. Child does not exhibit any delinquent behavior. B. Adequate social relationships. Child frequently interacts with social groups having positive support and influence; child displays age-appropriate social behavior; frequently participates in positive age-appropriate activities. Child engages with a positive support network. Child frequently displays age-appropriate solutions to social conflict. C. Situational concern. Child has a situational concern with peer/adult relationships as the result of an experience (ex. a new school, change of placement, relationship loss, etc.) that may require additional support. D. Limited social relationships. Child has limited peer/social relationships and limited adult support. Child demonstrates inconsistent social skills. Child has limited positive interactions with others and demonstrates limited ability to resolve conflicts. Child occasionally engages in high risk behavior/activities. E. Severely limited social relationships. Child has severely limited and/or negative peer social relationships, has minimal or lacks adult support, is isolated and lacks access to a support network. Child is unable to resolve social conflict. Child chronically engages in high risk behaviors/activities.  MACROBUTTON [2] "Click Here and Type"  ItemC9.Cultural/Community Identitya. Strong cultural/community identity +3b. Adequate cultural/community identity 0c. Situational concern -1d. Limited cultural/community identity -2e. Disconnected from cultural/community identity -3f. Unable to score US FORMDROPDOWN Item C9 CULTURAL/COMMUNITY IDENTITY A. Strong cultural/community identity. Child relates positively to his/her cultural, ethnic, and/or religious heritage. Child identifies with and participates in cultural and community heritage, beliefs, and practices. Child expresses age-appropriate inquiries about his/her cultural/community identity. B. Adequate cultural/community identity. Child relates to his/her cultural, ethnic, and/or religious heritage. Child has a developing sense of identity with his/her cultural and community heritage. Child expresses an age-appropriate awareness of his/her cultural/community identity. C. Situational concern. Child has a situational concern related to the development of a positive cultural/community identity, which causes an interruption in progress toward achievement of such an identity. D. Limited cultural/community identity. Child has some conflict with his/her cultural, ethnic, and/or religious heritage. Childs sense of identity with his/her cultural and community heritage is limited. Child does not express an age-appropriate awareness of his/her cultural identity. E. Disconnected from cultural/community identity. Child lacks a sense of identity with his/her cultural and community heritage, or has a sense of identity but his/her understanding of it results in negative self-concept, distorted perceptions about identity, and/or impaired social functioning.  MACROBUTTON [2] "Click Here and Type"  PRIORITY NEEDS AND STRENGTHS:Based on this assessment, identify below up to three priority needs and strengths of the child (indicate item code and title), if three needs have been scored. Priority needs are the top three domains with a negative number and priority strengths may be the domains that score 0 or a positive number. Address all situational concerns and priority items in the Individual Child Activities and Foster Parent/Relative sections of the Parent Agency Treatment Plan and Service Agreement. If a child has an identified need or situational concern in Medical/Physical, Mental Health and Well-Being and/or Education, it must be addressed with services regardless of priority. ASSESSMENT DOMAINSAREAS TO ADDRESS ON ISP/USPC1 Medical/Physical HealthStrengths: (list priority strength areas a and b responses):1. FORMDROPDOWN C2 Mental Health and Well-Being2. FORMDROPDOWN C3 Family and Kin/Fictive Kin3. FORMDROPDOWN  Relationships/AttachmentsC4 EducationOngoing Needs: (list priority need areas d and e responses)1. FORMDROPDOWN C5 Substance Use2. FORMDROPDOWN C6 Sexual Behavior3. FORMDROPDOWN C7 Life SkillsC8 Peer/Adult Social RelationshipsSituational Concerns: (list all areas assessed as situational concerns c responses)1. FORMDROPDOWN C9 Cultural/Community Identity2. FORMDROPDOWN 3. FORMDROPDOWN Other Child Strengths Provide information on any other strength for the child not identified in the needs and strengths assessment.  MACROBUTTON [2] "Click Here and Type"   D.Appropriateness of Placement: Based on the child needs assessment, explain why this placement is the most appropriate and least restrictive placement for the child. If the placement is not the least restrictive placement for the child based on the assessed needs, describe the appropriate placement for the child, the services needed to maintain the placement and the reasons for the continuation for residential placement..   MACROBUTTON [1] "Click Here and Type"   E.Prognosis for Placement in Family Setting or Independent Living: What is the prognosis for the child to be able to live in a family setting or independent living? What is the likelihood that the child will be able to live in a family setting or independently following completion of treatment at this facility? Explain how this placement will prepare and assist the child to live in a family setting or to live independently?   MACROBUTTON [1] "Click Here and Type"   F.Progress to Date and Parenting Time: Briefly summarize any changes in the family or the child since the current placement began. Describe current status of child including significant events since placement in this facility. List all visits between the child and others. Identify dates of visits including any missed or cancelled visits by any party. Describe compliance the parenting time plan and sibling visitation plan, if applicable and any other planned visitation or contacts with appropriate parties. List planned visits for the next planning period under goals and objectives for the child.   MACROBUTTON [1] "Click Here and Type"   G.Parent/Caretaker, Other Significant Individuals Feedback: Provide a summary of any input concerning the childs behavior; history, progress in treatment, etc., from parent/caretakers, siblings or other significant individuals (may be past or projected placements, foster care workers or other treatment providers.) Discuss parental or other significant persons support and cooperation with this placement and any barriers they may present to treatment.   MACROBUTTON [1] "Click Here and Type"   V.Family AssessmentThis section must be completed if the child has an identified family with a permanency planning goal of return home or if the placing agency has specified that the child will be placed with a parent. This section is not completed if the child is a permanent ward. The primary caretaker is the adult (typically the parent) living in the household who assumes the most responsibility for child care. When two adult caretakers are present and the worker is in doubt about which one assumes the most child care responsibility, the adult legally responsible for the children involved in the incident should be selected. If this rule does not resolve the question, the legally responsible adult who was a perpetrator should be selected. Only one primary caretaker can be identified in a household. If the child is a permanent ward or MCI and there is not an identified family, click no for the question below Does child have family participation in reunification and or treatment planning? and click on the Remove Family Assessment button. Do not complete the assessment for fictive kin or placement resources for the child unless DHS has identified the placement as a legal guardian or parent. If you need more than one family assessment click here. FORMTEXT      Does child have family participation in reunification and or treatment planning? Yes  FORMCHECKBOX  No  FORMCHECKBOX 1.Family History Who are the parents (biological, legal, putative), siblings, and perpetrators in the case? Who are others that have a role in the case whether as a perpetrator, placement alternative, or support, in or outside the household? Does the family have a history of prior placements in out of home care for this child or other family members .or prior CPS incidents. Why did this child come into care?. Include any other observations on intrafamilial relationships. and family functioning important to the placement of this child in out of home care  MACROBUTTON [1] "Click Here and Type"  2.Family Self Assessment What is the familys assessment of their functioning? What is the familys definition of the problem? Was it ever OK for the family? What is the family members definition of OK? What does the family think would make things better? What are their wishes? What resources does the family believe will help meet goals? Include an assessment of familys feelings of support from the relative network. Identify the relative network resources currently provided or available potential resources, and the resources from the surrounding community.  MACROBUTTON [1] "Click Here and Type"  3.Family Assessment of Needs and Strengths Briefly outline the observations and other facts that led to each individual item scored as a need or strength on the Family Assessment of Needs and Strengths for either caretaker. If there is more than one household involved in planning for the child, score both households separately. Rate the caretaker(s) on all items, except for Item S14. Select the score that applies to each caretaker under each category. For items where the worker is unable to obtain information at the ISP, Record US for Unable to Score If there are significant discrepancies between facility scoring of any need item and the worker with primary family responsibility, it must be resolved through a conference with the family worker  MACROBUTTON [1] "Click Here and Type"  Family Name FORMTEXT      Primary CaretakerSecondary CaretakerMost SeriousS1.Emotional Stability Behaviora. Exceptional coping skills +2b. Appropriate responses 0c. Some problems -3d. Chronic depression, severely low esteem, emotional problems -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S1. EMOTIONAL STABILITY BEHAVIOR A. Exceptional Coping Skills - Caretaker displays the ability to deal with adversity, crises, and long-term problems in a positive manner. Has a positive, hopeful attitude. B. Appropriate responses  Caretaker displays appropriate emotional responses. No apparent dysfunction. C. Some problems  Based on available evidence, caretaker's emotional stability appears problematic in that it interferes to a moderate degree with family functioning, parenting, or employment or other aspects of daily living. Indicators of "some" problems with emotional stability include: staff has repeatedly observed or been given reliable reports of indicators of low self-esteem, apathy, withdrawal from social contact, flat affect, somatic complaints, changes in sleeping or eating patterns, difficulty in concentrating or making decisions, low frustration tolerance or hostile behavior; frequent conflicts with coworkers or friends; few meaningful interpersonal relationships; speech is sometimes illogical or irrelevant; frequent loss of work days due to unsubstantiated somatic complaints; caretaker has been recommended for, or involved in, outpatient therapy within past two years; diagnosis of a mild to moderate disorder; or difficulty in coping with crisis situations such as loss of a job, divorce, or separation or an unwanted pregnancy. D. Chronic or severe problems - Caretaker displays chronic depression, apathy, and/or severe loss of selfesteem. Caretaker is hospitalized for emotional problems and/or is dependent upon medication for behavior control. observed, reported, or diagnosed chronic depression, paranoia, excessive mood swings; inability to keep a job or friends; suicide ideation or attempts; recurrent violence; stays in bed all day, completely neglects personal hygiene; grossly impaired communication (e.g., incoherent); obsessive/compulsive rituals; reports hearing voices or seeing things; diagnosed with severe disorder; repeated referrals for mental health/psychological examinations; recommended or actual hospitalization for emotional problems within past two years; severe impulsive behavior; or incapacitated by crisis situations.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS2.Parenting Skillsa. Strong skills s +2b. Adequate skills 0c. Improvement needed -3d. Destructive/abusive parenting -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S2. PARENTING SKILLS A. Strong Skills - Caretaker displays knowledge and understanding of parenting skills and is utilizing these skills with child(ren) on a daily basis. Parent shows an ability to identify positive traits in their children (recognize abilities, intelligence, social skills, etc.), encourages cooperation and a positive identification within the family. B. Adequate skills  Caretaker displays adequate parenting patterns which are age-appropriate for the child in the areas of expectations, discipline, communication, protection, and nurturing. Caretaker has the basic knowledge and skills to parent. C. Improvement needed  Improvement of basic parenting skills needed by caretaker. Caretaker has some unrealistic expectations, gaps in parenting skills, demonstrates poor knowledge of age-appropriate disciplinary methods, is ambivalent about parenting, and/or lacks knowledge of child development which interferes with effective parenting. Includes: frequent parent/child conflict over discipline; children sometimes left unsupervised; parents sometimes inattentive to child's emotional needs or are rejecting; any single preponderance of evidence referral for inappropriate discipline, violent behavior towards child(ren), lack of supervision, or failure to thrive (includes current); parent lacks knowledge/needs assistance in dealing with special needs child(ren); or occasional parent/child role reversal. D. Destructive/abusive parenting  Caretaker displays destructive/abusive parenting patterns. Based on available evidence, it appears that caretaker(s) uses extreme punishment, or that their actions are tantamount to emotional abuse/neglect or that caretaker has abdicated responsibility for supervision, protection, discipline and/or nurturance. Indicators include: two or more preponderance of evidence referrals for inappropriate discipline, violent behavior towards child(ren), lack of supervision, or failure to thrive (prior and current); caretaker makes it clear that child(ren) are not wanted in home; discipline routinely involves use of an instrument (belt, board) or unusual deprivation (lock in cellar or closet); routine badgering and belittling of child(ren); caretaker discipline and control completely ineffective or caretaker makes no effort; caretaker unable to prevent abuse by others; caretaker contributes to child's delinquent involvement; prior termination of parental rights for sibling(s); persistent parent-child role reversal; caretaker refuses/unwilling to acknowledge that child has been sexually abused.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS3.Substance Abusea. No evidence of problem 0b. Caretaker w/substance problem/current treatment issues -3c. Caretaker with serious problem -4d. Problems resulting in chronic dysfunction -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S3. SUBSTANCE ABUSE A. No evidence of problems  No evidence of a substance abuse problem with caretaker. Based on available evidence, it does not appear that the use of substances interferes with the caretaker's or the family's functioning. Use does not affect caretaker's employment, criminal involvement, marital or family relationships, or his/her ability to provide supervision, care, and nurturance for children. B. Caretaker with problem or current treatment issues  Caretaker displays substance abuse problem resulting in disruptive behavior or causing discord in family. Based on available evidence, it appears that caretakers substance abuse creates problems for the caretaker or the family. Consider as problems the following: the caretaker has been arrested once in the past two years for alcohol or drug-related offenses or has refused breathalyzer (PBT) testing; caretaker has experienced work-related problems in the past year as a result of substance use; staff have observed or received reliable reports that children have, on more than one occasion, been left unsupervised, inadequately supervised or let longer than planned by the caretaker because of substance abuse (i.e., caretaker physically absent due to use or passed out or seeking drugs); staff have observed or received reliable reports that caretakers substance abuse results in conflict in family over use (e.g., arguments between spouses or between children and caretaker over use); staff have observed withdrawal symptoms: twitching and tweaking (uneasiness), restlessness, runny nose, flu-like complaints, overly tired, multiple bathroom breaks in a short period of time, mood swings; house is in disarray, Activities of Daily Living not tended to; caretaker admits that he/she is experiencing some problems due to substance abuse; caretaker is currently in out-patient treatment (including AA/NA); caretaker has received treatment for substance abuse and has been in recovery for less than one year. OR, caretaker is currently receiving treatment or is attending a support program for substance abuse. C. Caretaker with serious problem  Caretaker has serious substance abuse problem resulting in such things as loss of job, problems with the law, family dysfunction. Based on available evidence, it appears that caretakers substance abuse creates serious problems for the caretaker or the family. Consider the following criteria as indicators of a serious problem: child born positive for drug exposure or Fetal Alcohol Disorder; caretaker has ever been fired for substance abuse (and has not sought or benefited from treatment); home raided; caretaker has been arrested two or more times for alcohol or drug-related offenses within the last year; staff have observed indicators of intoxication such as slurred speech, glassy eyes, unsteady gait, order of alcohol, drug paraphernalia; unusual strong order in home similar to cat urine, nail polish remover, ammonia or ether; large amounts of products such as cold medicines, antifreeze, drain cleaners, lantern fuel, duct tape, coffee filters, batteries or clear glass beakers and containers; reliable reports of, or staff have observed, violence toward family members by caretaker while under the influence; reliable reports of daily intoxication; caretaker has been diagnosed as substance dependent and has received treatment within past two years and is still using; child or spouse reports observation of caretaker using drugs, or children have knowledge of whereabouts of drugs in household; history of positive and/or missed urine screens and PBTs. Problems resulting in chronic dysfunction  Caretaker has chronic substance abuse problems resulting in a chaotic and dysfunctional household/lifestyle. There has been a pattern of serious, long-term problems related to substance abuse. Other examples may include but are not limited to: multiple job losses; multiple arrests that are related to the caretakers substance abuse; caretaker has had a serious problem with substance abuse, has been in treatment multiple times, and has had multiple relapses; caretaker has a serious medical problem(s) resulting from substance abuse: Hepatitis B, C or D, HIV, cirrhosis, esophageal problems, irritable bowel, acute pancreatitis, repeated Sexually Transmitted Diseases; toxic psychosis; extreme weight loss; there has been regular pre-natal exposure of children to substances - this includes exposure in more than one pregnancy, children diagnosed Fetal Alcohol Spectrum Disorder, or children medically determined substance dependent at birth.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS4.Sexual Abusea. No evidence of problem 0b. Caretaker has failed to protect child(ren) from sexual abuse -4c. Caretaker has abused child(ren) sexually -5d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S4. SEXUAL ABUSE A. No evidence of problem  Caretaker is not known to be a perpetrator of child sexual abuse. B. Failed to protect  Caretaker has failed to protect a child from sexual abuse. C. Evidence of sexual abuse  Caretaker is known to be a perpetrator of child sexual abuse.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS5.Domestic Relationsa. Supportive Relationship +2b. Single caretaker not involved in domestic relationship 0c. Domestic discord, lack of cooperation -2d. Serious domestic discord/domestic violence -4e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S5. DOMESTIC RELATIONS A. Supportive relationship  Supportive relationship exists between caretakers and/or adult partners. Caretakers share decision making and responsibilities. B. Single caretaker not involved in domestic relationship  Single caretaker. C. Domestic discord, lack of cooperation  Current marital or domestic discord. Lack of cooperation between partners, open disagreement on how to handle child problems/discipline. Frequent and/or multiple partners. D. Serious domestic discord/domestic violence  Serious marital discord or domestic violence. Repeated history of leaving and returning to abusive spouse or partners. Involvement of law enforcement in domestic violence problems, restraining orders, criminal complaints.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS6.Social Support Systema. Strong support system +2b. Adequate support system 0c. Limited support system -2d. No support or destructive relationships -4e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S6. SOCIAL SUPPORT SYSTEM A. Strong support system - Caretaker has a strong, constructive support system. Active extended family (may be blood relations or close friends) who provide material resources, child care, supervision, role modeling for parent and children, and/or parenting and emotional support. B. Adequate support system  Caretaker uses extended family, friends, community resources to provide a support system for guidance, access to child care, and available transportation, etc. C. Limited support system  Caretaker has limited support system, is isolated, or reluctant to use available support or support system is negative. D. No support or destructive relationships  Caretaker has no support system and/or caretaker has destructive relationships with extended family and community resources.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS7.Communication/Interpersonal Skillsa. Appropriate skills 0b. Limited or ineffective skills -2c. Isolating/hostile/destructive -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S7. Communication/Interpersonal Skills A. Appropriate skills  Caretaker appears to be able to clearly communicate needs of self and children and to maintain both social and familial relationships. B. Limited or ineffective skills  Caretaker appears to have limited or ineffective interpersonal skills within the family and community which limit ability to make friends, keep a job, communicate needs of self or children to schools or agencies. C. Isolated/hostile/destructive  Caretaker isolates self/children from outside influences or contact, and/or have interpersonal skills that are hostile/destructive towards family members or others. Available evidence indicates very chaotic, disrespectful communication or behavior patterns or extreme isolation; very diffuse or extremely rigid personal boundaries; extreme emotional separateness or attachment.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS8.Housinga. Adequate housing 0b. Some housing problems, but correctable -2c. No housing, eviction notice -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S8. HOUSING A. Adequate housing  Family has adequate housing of sufficient size to meet their basic needs. B. Some housing problems, but correctable - Family has housing, but it does not meet the health/safety needs of the children due to such things as inadequate plumbing, heating, wiring, housekeeping, or size. C. No housing, eviction notice  Family has eviction notice, house has been condemned, is uninhabitable, or family has no housing.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS9.Intellectual Capacitya. Average or above functional intelligence 0b. Some impairment, difficulty making skills -2c. Severe limitation -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S9. INTELLECTUAL CAPACITY A. Average or above functional intelligence  Caretaker appears to have average or above average functional intelligence. B. Some impairment, difficulty in decision making skills  Caretaker has limited intellectual and/or cognitive functioning which impairs ability to make sound decisions or to integrate new skills being taught, or to think abstractly. Available evidence indicates that caretaker's intellectual ability impairs their ability to function independently and to care for child(ren). Indicators include: deficiencies, even after instruction, in everyday living skills such as taking a bus, shopping for food or clothing, or using money; difficulties in performing, even after instruction, such basic child care tasks as preparing formula, changing diapers, taking temperatures, administering medication, preparing meals, or dressing children appropriately for weather conditions; grossly inappropriate social behavior for chronological age; previous school placement in a special education or developmental disabilities program; caretakers' IQ indicates that he/she is mentally impaired (score of 50-55 to approximately 70).  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS10.Literacya. Literate 0b. Marginally literate -2c. Illiterate -3d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S10. LITERACY A. Literate - Caretaker has functional literacy skills, is able to read and write adequately to obtain employment, and assist children with school work. B. Marginally literate  Caretaker has marginally functional literacy skills that limit employment possibilities and ability to assist children. C. Illiterate  Caretaker is functionally illiterate and/or totally dependent upon verbal communication. D. Severe limitation  Caretaker is limited intellectually and/or cognitively to the point of being marginally able or unable to make decisions and care for self, or to think abstractly. It appears that the caretaker has severely limited intellectual ability and that it seriously limits or prohibits ability to function independently and to care for child(ren). Indicators of a major problem include: caretakers IQ indicates that he/she is moderately, severely, or profoundly mentally impaired (score below 50-55); caretaker's employment is in a sheltered workshop or is unable to work; outside assistance is provided or has been recommended for caretaker's daily living; previously placed in, or recommended for, residential treatment facility, or specialized group home because of limited intellectual ability; inability to recognize and respond appropriately to situations requiring prompt medical attention (e.g., diarrhea, fever, vomiting) or emergency medical care (e.g., potential broken bones, serious burns) for family members; restricted ability to make judgments to protect the child(ren) from abuse, neglect, or injury.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS11.Resource Availability/Managementa. Strong money management skills +1b. Sufficient income to meet needs 0c. Income mismanagement -2d. Financial crisis -3e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S11. RESOURCE AVAILABILITY/MANAGEMENT A. Strong money management skills  Family has limited means and resources but family's minimum needs are consistently met. B. Sufficient income  Family has sufficient income to meet basic needs and manages it adequately. C. Income mismanagement  Family has sufficient income, but does not manage it to provide food, shelter, utilities, clothing, or other basic or medical needs, etc. D. Financial crisis  Family is in serious financial crisis and/or has little or no income to meet basic family needs.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS12.Employmenta. Employed +1b. No need 0c. Unemployed but looking -1d. Unemployed, not interested -2e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S12. EMPLOYMENT A. Employed - One or both caretakers are gainfully employed. B. No need - One or both caretakers are gainfully employed, or are out of labor force, e.g., fulltime student, disabled person, or homemaker. C. Unemployed, but looking  One or both caretakers need employment or are under-employed and engaged in realistic job seeking or job preparation activities. D. Unemployed, but not interested  One or both caretakers need employment, have no recent connection with the labor market, are not engaged in any job preparation activities nor seeking employment.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS13.Physical health Issuesa. No problem 0b. Health problem or physical limitation that affects family -1c. Serious health problems or physical limitation -2d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S13. PHYSICAL HEALTH ISSUES A. No problem  Caretaker does not have health problems that negatively affect family functioning. B. Health problem, physical limitation that negatively affects family - Caretaker has a health problem or physical limitation that negatively affects family functioning. This includes pregnancy of the caretaker. C. Serious health problem, physical limitation  Caretaker has a serious/chronic health problem or physical limitation that affects ability to provide for and/or protect children.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS14.Child Characteristicsa. Age appropriate, no problems 0b. Minor physical, emotional, intelligence problems -1c. One child has severe/chronic problems that result in substantial dysfunction -2d. Children have severe/chronic problems that result in substantial dysfunction -3e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S14. CHILD CHARACTERISTICS A. Age appropriate  Child(ren) appears to be age-appropriate, with no abnormal or unusual characteristics. B. Minor problems  Child(ren) has minor physical, emotional, or intellectual difficulties. Minor child is pregnant. C. Significant problems - One child has significant physical, emotional, or intellectual problems resulting in substantial dysfunction in school, home, or community which puts strain on family finances and/or relationships. D. Severe problems  More than one child has significant physical, emotional, or intellectual problems resulting in substantial dysfunction in school, home, or community which puts strain on family finances and/or relationships.  MACROBUTTON [1] "Click Here and Type"  Based on this assessment, identify below the priority needs and strength of the family below (indicate S code only). Address the priority items in the Treatment Plan and Service Agreement and any needs scored under Substance Abuse:Household Name: FORMTEXT      PRIMARY NEEDSS1 Emotional Stability BehaviorS8 Housing1. FORMDROPDOWN S2 Parenting SkillsS9 Intellectual CapacityS3 Substance AbuseS10 Literacy2. FORMDROPDOWN S4 Sexual AbuseS11 Resource Availability / MgmtS5 Domestic RelationsS12 Employment3. FORMDROPDOWN S6 Social Support SystemS13 Physical Health issuesS7 Comm. / Interpersonal SkillsS14 Child CharacteristicsPRIMARY STRENGTHSS1 Emotional Stability BehaviorS8 Housing1. FORMDROPDOWN S2 Parenting SkillsS9 Intellectual CapacityS3 Substance AbuseS10 Literacy2. FORMDROPDOWN S4 Sexual AbuseS11 Resource Availability / MgmtS5 Domestic RelationsS12 Employment3. FORMDROPDOWN S6 Social Support SystemS13 Physical Health issuesS7 Comm. / Interpersonal SkillsS14 Child Characteristics4.Family Strengths Provide information on any other strength for the family not identified in the needs and strengths assessment.  MACROBUTTON [1] "Click Here and Type"   FORMTEXT       VI. PARENT  AGENCY TREATMENT PLAN AND SERVICE AGREEMENT This treatment plan is developed to assure that each child will receive safe and proper care and services by the following activities. A. SERVICE REFERRAL TABLEBarrier/Needs Addressed C1 = Medical/Physical Health C2 = Mental Health and Well Being C3 = Family and Kin/Fictive Kin Relationships/Attachments C4 = Education C5 = Substance Use C6 = Sexual Behavior C6 = Life Skills C8 = Peer/Adult Social Relationships (Non-Family) C9 = Cultural Community Identity S1 = Emotional Stability S2 = Parenting Skills S3 = Substance Abuse S4 = Sexual Abuse S5 = Domestic Relations S6 = Social Support System S7 = Communication/Interpersonal Skills S8 = Housing S9 = Intellectual Capacity S10 = Literacy S11 = Resource Availability/Management S12 = Employment S13 = Physical Health Issues S14 = Child CharacteristicsService Referral Type Codes AD = Alcohol / Drug Abuse Rehabilitation DC = Day Care DV = Domestic Violence ED = Education FC = Family / Outreach Counseling FR = Reunification Services HS = Homemaker Services or Parent Aid IL = Independent Living JT = Job Training MD = Medical ServicesMH = Mental Health Services OT = Other Program Needs PS = Parenting Skills Training TH = Individual / Group Therapy WP = Wrap Around Family Member Name Barriers/ Needs Addressed  Service Type Code  Service Provider Name  Mo/Yr Re- ferred  Mo/Yr Start Target Com- pletion Date (Mo/Yr) Service Status  Completed Services  Com- pletion Date (Mo/Yr)  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       Parent - Agency Treatment Plan and Service Agreement (continued) In this section, provide the specific goals, objectives, activities, and parenting time (schedule and expected activities), sibling visitation and other activities for all parties, the placement provider, the child, and the foster care worker. The goals and objectives must be clear, measurable, with expected outcomes to assist the child to live in the least restrictive setting possible.B. Goals, Objectives and Expected Outcomes 1. List childs service goals and action steps (include time frames and responsibility). Goals should address areas prioritized on Child Needs and Strengths Assessment and activities of daily living (if applicable). Identify what agency and parent(s) need to do to meet these specific needs. 2. If the child is age 14 or older (including those wards who become 14 years of age during the report period), include a description of the programs and services which will assist the youth to prepare for the transition to a state of functional independence or the ability to take care of oneself physically, socially, economically and psychologically and identify where, how and by whom these services are to be provided.   MACROBUTTON [b2] "Click Here and Type"   C. Parent Activities - If child is permanent ward or has no participating parent, write NA. 1. List each goal for parent(s) and non-parent adult(s), if applicable, specific action steps, time frame for achieving, and expected outcome. Goals must address the areas prioritized on the Family Assessment of Needs and Strength. If applicable, specify involvement in medical and dental appointments, attendance at school conferences and in treatment with the child. Identify how the facility will coordinate the activities with the supervising agency. 2. Indicate if employment, day care, and/or transportation is a barrier to the parent meeting any of the goals or action steps including parenting time. Indicate the plan to address any of these three items.   MACROBUTTON [b2] "Click Here and Type"   D. Residential Care Treatment Activities 1. Identify clinical services to be provided to the child and family and all other parties, as appropriate. This includes any other potential placement for the child. 2. Identify day to day activities completed by facility staff. 3. State proposed residential worker contact with the child and family, if applicable. 4. For each ward age 14 or older (including those wards who become 14 years of age during the report period), include a description of the programs and services which will assist the youth to prepare for the transition to a state of functional independence or the ability to take care of oneself physically, socially, economically and psychologically. Identify where, how and by whom these services are to be provided. (See CFF 722-6 Independent Living Preparation.)   MACROBUTTON [b2] "Click Here and Type"   E. Parenting Time Identify under worker activities what the agency will do to facilitate parenting time. Identify here what the parent must do during parenting time with the child. If there is no parent, Write NA) in the space provided below. 1. 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