Alabama QSR Write-up
Child’s Initials:Case Number: County:
Service Category:CPS FC SEBD
Case Worker:Review Date:
Reviewer Name: Number of Persons Interviewed:
Child’s Age:Child’s Gender: Male Female
Child’s Race: White/Caucasian American Indian or Alaska Native
Black/African American Native Hawaiian or Pacific Islander Asian
Unknown Unable to Determine Other
Child’s Ethnicity: Hispanic/Latino Yes No Unknown
Number of Months Case Open (most recent opening):
Current Placement: Birth Home Hospital/ Mental Health Shelter
Foster Home Relative Home Res. Treatment
Group Home Adoptive HomeSupervised IL
DetentionDYS Approved Kinship Care
Other:
Total Number of Placements:
Placed with Siblings: All Some None N/A (No Sibs or CPS Case)
Referral Type: Child Protect Other Referral
Referral Reason:
Reason for Case Opening: Unknown Neglect Adoption Disruption
Delinquent Sexual Abuse Physical Abuse
Other:
Family Issues at Time of Case Opening:
Domestic Violence Yes No
Absent Parent Yes No
Substance Abuse Yes (Specify) No
Crystal Meth/Crank Cocaine/Crack Heroin
MarijuanaAlcoholPrescription Drugs
Other:
Mental Health Yes (Specify) No
Depression Bi-PolarAnxiety Disorders
Schizophrenia Personality Disorder MR
Other: ______
Permanency Plan: Goal Concurrent
Remain with Parents
Return to Parents
APPLA – Court Approved
Foster Parent Adoption
Adoption (with no identified resource)
Permanent Relative Placement w/ Transfer of Custody
Permanent Relative Placement w/ DHR Retaining Custody
Adult Custodial Care
School Placement: Regular Education Special Education N/A
Grade Level: 1 2 3 4 5 6 7 8 910 11 12
Pre-School KindergartenPostHigh School
Planned Child Transitions over the next 6 months (Check all that Apply):
Next Grade/New School Child to Adult Services Discharge from IL
Return Home School to Work Discharge from Juv. Jus. Sup.
Planned Step Down Grad. To PostSecondary School Entry into Military
Change of Custody Discharge from Foster Care Entry into Job Corps
Other:
Bio-Family Living Status:
Owns Home Rents Home Apartment
With Another Family Member Homeless Shelter
Other:
Bio-Family Economic Status (Check all that Apply):
SSI/Social SecurityFood Stamps Child Support
TANF Salary/Wages Military Benefits
Unemployment Compensation Other:
Transitions/Family Adjustments over the last 3 months and/or anticipated for the next 6 months
(Check all that apply):
New Job/Work Schedule Layoff/Job Loss
New Residence Loss of Home New Member/Baby
Change of Custody Serious MH Crisis School Change/Suspension
Fam Member Reunification Divorce of Birth Parents Loss of Family Member/Death
Serious Illness/Injury Victim of Serious Crime Victim of Natural Disaster
Loss of TANF/Benefits Incarceration of Family Member
Other:
Child’s Current Diagnosis/Disability (Check all that Apply): None
Mental Health/MR: ADHD ADD ODD Conduct Disorder
PTSD MRDepression
Other:
Diabetes Asthma Seizures Substance Abuse
Vision Impairment Hearing Impairment
Physical Disability (Specify):
CountyName: / Child’s Initials:Status Indicator
/Performance Indicator
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 61. Safety of the Child / 1. Child/Family
Engagement
1 / 2 / 3 / 4 / 5 / 6 / N/A / 1 / 2 / 3 / 4 / 5 / 6
2. Safety of the Caregiver / 2. Assessment
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6
3. Stability / 3. Long Term View
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6
4. Appropriateness of / 4. ISP
Placement
1 / 2 / 3 / 4 / 5 / 6 / N/A / 1 / 2 / 3 / 4 / 5 / 6 / N/A
5. Maintaining Family / 5. Service
Connections / Coordination
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6 / N/A
6. Permanence / 6. Successful
Transitions
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6
7. Health/Physical / 7. Monitoring and
Well-Being / Modifications
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6
8. Emotional Well-Being / 8. Resource Avail./
Utilization
1 / 2 / 3 / 4 / 5 / 6 / N/A / 1 / 2 / 3 / 4 / 5 / 6 / N/A
9. Education / 9. Family
Preservation
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6
10. Responsible Behavior / 10. Family Support
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6 / N/A
11. Caregiver / 11. Urgent Response
Functioning
1 / 2 / 3 / 4 / 5 / 6 / N/A / 1 / 2 / 3 / 4 / 5 / 6
12. Family Progress / 12. Agency Response
1 / 2 / 3 / 4 / 5 / 6
13. Cultural
Accommodations
1 / 2 / 3 / 4 / 5 / 6
14. Satisfaction
1 / 2 / 3 / 4 / 5 / 6 / 1 / 2 / 3 / 4 / 5 / 6
15. Overall / 13. Overall
Please circleNA, Strength or Area Needing Improvement for each item that is being completed.
Questions 1- 5 are Foster Care Only (Applies to the target child only)
- Where is the child placed:
- Same Community
- Same county
- Out of County
- Out of state
For children placed out of the community, county or state, was the reason for the location clearly related to helping the child achieve their case plan goals (CHECK one): Yes No
Where is the child placed? (Treatment, Foster Home, Therapeutic Foster Home, Relatives, etc.)
CHECK One: NA Strength Area Needing Improvement
NA = 1) parent’s whereabouts are unknown, despite agency efforts to locate them, 2) parents are deceased, 3) parental rights are terminated with no planned involvement of the parents in case planning or case goals.
- Is the child placed with siblings who also are in foster care (CHECK one):
- Placed with all siblings who are in FC
- Placed with one or more siblings who are in FC
- Placed apart from all siblings who are in FC
- NA
If child is not placed with all siblings in FC, was there clear evidence that separation was necessary to meet the needs of the children (CHECK one): Yes No
CHECK One: NA Strength Area Needing Improvement
NA = child has no siblings placed in foster care.
- Are/were the primary connections and characteristics of the child being preserved in the foster care placement (CHECK one): Significantly Partially Not at all
Connections refer to ties with family members and other related or non-related individuals with whom the child in foster care has/had a significant, positive relationship before entering foster care.
Characteristics of the child refer to positive aspects of the values, beliefs, religion, language, traditions, and other factors that distinguish the identity of the child and the child’s family.
If the child is Native American are/were his interests being addressed through timely notification of the tribe and placement with the child’s extended family or tribe (CHECK one): Yes No NA
CHECK One: NA Strength Area Needing Improvement
- Is the child placed with relatives (CHECK one):YesNo
If not, were relatives considered for placement of the child (CHECK one):YesNo
Were both maternal/paternal relatives considered (CHECK one):YesNo
If the child required special services/placement, was an assessment made to that effect and did the agency
also determine that relative placements did not have the capacity, even with wrap-around services, to meet
the child’s needs (CHECK one): YesNo
CHECK One: NA Strength Area Needing Improvement
- Is there evidence of a strong, emotionally supportive relationship between the child and mother (CHECK one): Yes No NA (contrary to safety interests)
Is there evidence that DHR made efforts to promote/maintain such a relationship (CHECK one):
Yes No NA (contrary to safety interests)
Is there evidence of a strong, emotionally supportive relationship between the child and father (CHECK one): Yes No NA (contrary to safety interests)
Is there evidence that DHR made efforts to promote/maintain such a relationship (CHECK one):
YesNoNA
CHECK One: NA Strength Area Needing Improvement
NA = the relationship of the child with the parents is contrary to the child’s safety or best interests
Complete Questions 6 - 8 for Both CPS and FC Cases
NOTE for Question #6:If this review is on a child in foster care, item (#6) applies to the target child only. If this review is on a child in CPS, this item applies to all children residing with the family or receiving services.
- What was the most typical pattern of visitation between the worker and child (FC) or children (CPS) – (CHECK one):
- Weekly
- Bi-weekly
- Monthly
- Less than monthly
Is the frequency of visits consistent with the needs of the child(ren) (CHECK one): YesNo
Do the visits between the worker and child(ren) focus on issues pertinent to the ISP and its implementation (CHECK one): Yes No
CHECK One: NA Strength Area Needing Improvement
NOTE for Question 7:If this review is on a child in foster care, this item (#7) applies to visits with parents relative to the target child only. If this review is on a child in CPS, this item applies to visits with parents relative to all children residingwith the family or receiving services.
- What was the most typical pattern of visitation between the worker and mother (CHECK one):
- Weekly
- Bi-weekly
- Monthly
- Less than monthly
- NA
What was the most typical pattern of visitation between the worker and father (CHECK one):
- Weekly
- Bi-weekly
- Monthly
- Less than monthly
- NA
When visits occur less than monthly, is the frequency of visits consistent with the needs of the child(ren) (CHECK one): Yes No
Do the visits between the worker and parents focus on issues pertinent to the ISP and its implementation (CHECK one): Yes No
CHECK One: NA Strength Area Needing Improvement
NOTE for Question #8:If this review is on a child in foster care, the child involvement in the ISP applies to the target child only (if age-appropriate). If this review is on a child in CPS, the child involvement in the ISP applies to all age-appropriate children residing with the family or receiving services.
- Were all appropriate members of the family involved in the ISP, including fathers and absent parents (CHECK one): Yes No
Were efforts made to engage family members and was the input and opinions of family members actively
considered in the development of the ISP (e.g. identifying strengths/needs, establishing goals,
identifying services, etc.) (CHECK one). Yes No
Were attempts made to locate and involve absent parents (CHECK one):Yes No
CHECK One: NA Strength Area Needing Improvement
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Six Month Prognosis: ImproveContinue Status Quo Decline/Deteriorate
QSR Outcome Category(Overall Child & Family Status/Overall System Status):
1. + + 2. - + 3. + - 4. - -
CASE REVIEW SUMMARY
PERSON’S INTERVIEWED BY ROLE (Child, Mother, Teacher, etc.)