/ SafeCare
End of Service Summary /
DATE OF REPORT
/ AGENCY PROVIDING SERVICE / PHONE NUMBER (INCLUDE AREA CODE)
DATE OF REFERRAL / SAFECARE HOME VISITOR / CA SOCIAL WORKER
TERMINATION DATE / FAMLINK CASE ID # / FAMILY NAME
PLACEMENT PRESERVATION/PLACEMENT PREVENTION / REUNIFICATION
Summary of SafeCare Service
CLIENT NAME / SAFECARE MODULE / SAFECARE MODULE OUTCOME
CHILD HEALTH / Choose an item.
HOME SAFETY / Choose an item.
PARENT CHILD or PARENT/INFANT INTERACTION, / Choose an item.
CHILD HEALTH / Choose an item.
HOME SAFETY / Choose an item.
PARENT CHILD or PARENT/INFANT INTERACTION, / Choose an item.
CHILD HEALTH / Choose an item.
HOME SAFETY / Choose an item.
PARENT CHILD or PARENT/INFANT INTERACTION, / Choose an item.
CHILD HEALTH / Choose an item.
HOME SAFETY / Choose an item.
PARENT CHILD or PARENT/INFANT INTERACTION, / Choose an item.
SafeCare Modules
Child Health / Teaches parents to keep children as healthy as possible, to use health reference materials, to keep good health records, and to recognize when children are sick or injured, to distinguish when symptoms can be cared for at home, need a doctor’s attention, or need emergency services.
Home Safety / Teaches parents to understand the importance of home safety and supervision and helps parents develop knowledge and skills in finding and removing household hazards.
Parent-Child Interaction / Helps parents learn positive interaction skills, to use organized processes for all activities, and how to engage children in age-appropriate activities.
Parent-Infant Interaction / Teaches parents how to increase positive interactions with their infant that support development, how to enhance their responsiveness to infant needs and signals, and supports a parent in learning about infant development and planning age-appropriate activities. The goals work together to help parents bond with their infant.
Pre/Post Scoring of CANS-F
Completed this section ONLY for the CANS-F Needs that were targeted by this specific intervention, provide a post intervention score

Treatment Target Areas

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Pre

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Post

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Positive Change

/ Comments

Provide detailed information about any score that remains a 2 or 3 that was relevant to the intervention.

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If SafeCare was not completed for any reason, please describe the circumstances that contributed to the family not completing a specific module or the entire service.
Describe specific ways that the family has improved their home environment to increase sustainable child safety:
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Identify natural (church, family, school, friends, etc.) and community (mental health, CSO, YWCA, etc.) resources that the family has identified to help address the child safety issues and their progress in utilizing these services :
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Document the families perspective on how their parenting has changed during this intervention:
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Document the SafeCare Home Visitor assessment of change during this intervention:
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Briefly describe what tasks or goals were accomplished during the case related family support hours (if used):
Detail additional services or supports that may increase safety, functioning, and stability of the family:
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SAFECARE HOME VISITOR SIGNATURE / DATE

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Children’s Administration November 1, 2016