Brief Intensive Services

Brief Intensive Services

Initial Family Assessment

NCFAS-G

Today’s Date:
Child’s Name: / Child’s DOB:
Admission Date: / Discharge Date:
Completed by:

Reason for Referral:

For each of the domains listed below, provide the NCFAS-G overall rating:

A. Environment

Sub-scales to consider: housing stability, safety in the community, habitability of housing, income/employment, financial management, food and nutrition, personal hygiene, transportation, learning environment.

Clear Strength / Mild Strength / Baseline/
Adequate / Mild Problem / Moderate Problem / Serious Problem

B. Parental Capabilities

Sub-scales to consider: supervision of children, disciplinary practices, provision of developmental/enrichment opportunities, parent(s)/caregiver(s) mental health, parent(s)/caregiver(s) physical health, parent(s)/caregiver(s) use of drugs/alcohol.

Clear Strength / Mild Strength / Baseline/
Adequate / Mild Problem / Moderate Problem / Serious Problem

C. Family Interactions

Sub-scales to consider: bonding with child(ren), expectations of the child(ren), mutual support within the family, relationship between parents/caregivers.

Clear Strength / Mild Strength / Baseline/
Adequate / Mild Problem / Moderate Problem / Serious Problem

D. Family Safety

Sub-scales to consider: absence/presence of physical abuse of child(ren), absence/presence of sexual abuse of child(ren), absence/presence of emotional abuse of child(ren), absence/presence of neglect of child(ren), absence/presence of domestic violence between parents/caregivers.

Clear Strength / Mild Strength / Baseline/
Adequate / Mild Problem / Moderate Problem / Serious Problem

E. Child Well-Being

Sub-scales to consider: child(ren)’s behavior, school performance, child(ren)’s relationship with parent(s)/caregiver(s), child(ren)’s relationship with sibling(s), child(ren)’s relationship with peers, cooperation/motivation to maintain the family.

Clear Strength / Mild Strength / Baseline/
Adequate / Mild Problem / Moderate Problem / Serious Problem

F. Social/Community Life

Sub-scales to consider: social relationships, relationships with child care, schools and extracurricular services, connection to neighborhood, cultural/ethnic community, connection to spiritual/religious community, parent(s)/ caregiver(s)’s initiative and acceptance of available help/support.

Clear Strength / Mild Strength / Baseline/
Adequate / Mild Problem / Moderate Problem / Serious Problem

G. Self-Sufficiency

Sub-scales to consider: caregiver employment, family income, financial management, food and nutrition, transportation.

Clear Strength / Mild Strength / Baseline/
Adequate / Mild Problem / Moderate Problem / Serious Problem

H. Family Health

Sub-scales to consider: parent(s)/caregiver(s)’s physical health, parent(s)/caregiver(s)’s disability, parent(s)/caregiver(s)’s mental health, child(ren)’s physical health, child(ren)’s disability, child(ren)’s mental health, family access to health/mental health care.

Clear Strength / Mild Strength / Baseline/
Adequate / Mild Problem / Moderate Problem / Serious Problem

Narrative Section

The narrative description should include any significant strengths and problem areas identified in the sub-scales:

Adapted from the Initial Family Assessment for the NCFAS and NCFAS-R scales with permission from the developer, Institute for Family Development.

S:\Secretaries\Briana\Forms\FBS Program Forms\Brief Intensive Services\Discharge Packet

Revised June 2012