SERVICES CHECKLIST
Department of Human Services
Family Name: / FFM Worker:
Termination Date: / FFM Agency: / Code:
Checkmark below any services provided to the family. All marked services should be able to be found recorded in your case notes or weekly case summaries and your reports.
I. RISK ASSESSMENT & RISK MANAGEMENT:
Provide business card & explain 24/7 procedures / Child monitoring & supervision
Risk assessment / Identification of appropriate caregivers
Environmental safety assessment / Use of crisis card
Suicide assessment & prevention / Safety planning
De-escalating/defusing crisis / Pre-empting crisis
Routine direct inquiry regarding DV / Identifying crisis
Developmental safety considerations / Health management issues
Lethality assessment / Other (specify)
II. FAMILY VIOLENCE INFORMATION & SAFETY PLANNING
DV / FF / Note:Workers taking cases referred by DV programs must also review gray shaded column and mark if client received
such services from referring DV program. Client may receive services from both DV & FFM.
Use of and roles within the legal system [police, Friend of the Court, etc.]
How to obtain or use a personal protection order
Safety planning with victim and family
Emergency planning / escape routes
Planning to leave
Dynamics of domestic / family violence
Effects on children of witnessing/experiencing violence
General Custody / Visitation information
Addressing specific Visitation issues
Identification of appropriate caregivers
Other (specify)
III. SUBSTANCE ABUSE SERVICES:
Education about substance abuse & recovery / Confrontation with client/family
Commitment to sobriety/abstinence / Relapse prevention planning
Accompanied to self help meetings / Identify a sponsor
Identification and assessment of use / Effects of substance abuse on children
Other (specify)
IV. SEXUAL ABUSE SERVICES:
Boundaries concepts / Age appropriate sexual development
Sexual abuse education / Identification of signs and symptoms
Prevention skills / Linking to approp. sexual abuse services
Identifying appropriate treatment services / Other (specify)
V. GENERAL CLINICAL SERVICES:
Parenting/Limit Setting:
Natural/logical consequences / Child/adolescent development
Time out / Clarifying problem behaviors
Parent as role model / Structure routine
Improving child compliance / Clarifying family rules
Family meeting(s) / Tracking/charting behavior
Clarifying family roles / Identification of appropriate caregivers
Other (specify)
Emotion Management:
Anger management / Use of crisis card
Depression management / R.E.T. concepts
Anxiety/confusion management / R.E.T. techniques
Self-criticism reduction / Pleasant events
Building self-esteem / Relaxation
Handling frustration / Tracking emotions
Impulse management / Use of journal
Building hope / Stress management
Process of change / Other (specify)
Personal & Interpersonal Skills:
Conversational/social skills / Appropriate sexual behavior
Problem solving / Accepting “no”
Negotiation skills / Giving/accepting feedback
Boundary concepts / Fair fighting guidelines
Teaching “I” messages / Money management
Teaching active listening / Time management
Relationship building / Academic skills
Values clarification / Employability skills
Understanding/reframing system requirements / Assertiveness
Other (specify)
Additional Clinical:
Therapeutic games / Use of reinforcement
Worker as role model / Active listen to client family
Providing & review literature / Role playing/Response exercise
Video presentations / Paper pencil tests
Other (specify)
VI. REFERRAL TO OTHER RESOURCES…
Substance abuse assessment/treatment-DV victim / Substance abuse assessment & treatment
Substance abuse assessment/treatment-perpetrator / Credit Counseling
Domestic Violence shelter / Counseling Services
Domestic Violence non-residential services / Self-help Group
Domestic Violence victim support group / Social Services
Domestic Violence batterer’s intervention program / Mental Health
Domestic Violence Legal Advocate / Linking to approp. sexual abuse services
Other (specify)
VII. ADVOCACY WITH…
Social services / Legal system to obtain PPO
Mental Health system / Legal system for custody arrangements
Utility companies / Court or legal system for
Health Care/Medical system / Law Enforcement
Education system / Prosecutor’s Office
Child Care providers / Domestic Violence Shelter Staff
Landlord / Domestic Violence Victim Advocate
Employer / Other (specify)
VIII. LINKAGE WITH SOCIAL SUPPORTS
General relationship building skills
Family/Kin/Fictive Kin
Neighbors
School [e.g. PTO, Homeroom Parent, LSCO, Head Start]
Civic Organizations / Community Activities [e.g. Neighborhood Watch, TribalCenter, Bowling League]
Faith Communities [e.g. Church, Bible Study, Synagogue, Mosque]]
Child Organizations/Mentors [e.g. big Brother/Big Sister, 4H, Boy/Girl Scouts]
Child Support Group (specify)
Parent Aides/Mentors [e.g. Building Strong Families, Foster Grand Parents]
Adult Support Group (specify)
Paid/Unpaid Work Site [e.g. including volunteer activities/groups]
Other Social Support (specify)
X. PROVISION OR ASSISTANCE WITH CONCRETE SERVICES:
$ / Also mark the box in the $ sign column if Specific Assistance to Individuals Funds were used for the service
Transportation
Food
Financial assistance
Child care / baby-sitting
Clothing
Legal assistance
Housing
Phone
Other utility benefits or services
Doing housework/cleaning or help client obtain homemaker services
Medical/dental services
Job search assistance
Provide or help client get a job
Furniture/household goods
Provide toys or recreational equipment/activities
Educational services/supplies
Home security (locks, windows, lighting, security system)
Other (specify)
Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
DHS-238 (Rev. 6-06) Previous edition obsolete. MS Word1FFM Mandatory Form