Family Based Services, LLC

Family Based Services, LLC

Working to Keep Families Together

P.O. Box 48

Charmco, WV 25958

Phone: (304)438-9136

Fax: (304)438-6269

Family Assessment

Case Name: ______Facts#: ______

Presenting Problem: (Describe maltreatment/misbehavior, or family dysfunction. Identify individuals involved, circumstances and family response)

Service Summary: (P- previously provided, C-currently provided, N/A-not applicable)

CPS _____Medicaid _____Day Care _____

AFDC _____Counseling _____Homemaker _____

SSI _____Housing _____Legal _____

FS _____Medical _____Youth Services _____

Juvenile Court Involvement _____

Summary of Previous Service Involvement:

Family Functioning:

1. Parent Characteristics:

Characteristic / Mother / Father / Explanation
Drug Abuse
Alcohol Abuse
Medical Problem
Emotional Problems
Criminal Involvement
Sexually abusive to children
Sexually abusive to spouse
Verbally abusive to children
Verbally abusive to spouse
Physically abusive to children
Physically abusive to spouse
Frequently absent
Steadily employed
Nurturing
Handles crisis well
Insightful
Sets realistic limits on child
Cooperative with agencies
Amenable to counseling
Tends to physical needs of child
Reliable
Good self expression
Has understanding of child development

1. Family Medical History:

(S-suspected, I-identified)

Enter children by first name

History / Mother / Father
Birth defects/injury
Visual
Hearing
Orthopedic
Speech/Language
Physical Appearance
Serious Disease
Serious Injuries
Disabilities
Mental/Emotional

Are copies of medical/immunization reports in the case record? If so list.

Names and addresses of physician/clinic for health care and immunizations.

Are health problems or conditions a barrier to the child remaining in the home?

If yes, explain.

1. Home Environment

Describe physical setting of the home, noting any hazards that place the children at risk or acts as barriers to child returning home.

1. Educational History:

Adults / Mother / Father / Other
Last Grade Completed
Specialized Training
Children
Grade
School
Special Education
Behavior Disorder
Date of I.E.P.
Truancy
Academic Difficulty

Is parent(s) educational level a barrier to the child remaining/returning to the home?

Is placement being explored because of local school system’s inability to meet the child’s needs?

1. Family Interaction:
2. Description of family roles/relationships, involvement of extended family:

1. Marital History: (previous and current relationships – duration etc.)

1. Attitudes toward parenting:

1. Division of labor/chores:

1. Previous and current living patterns and housing arrangements:

1. Treatment of children:
2. Description of maltreatment: (If any)

1. What behavior/conditions led to the maltreatment:

1. Effects of maltreatment on children:

1. Removal of children:

Child / Date of removal / Reason for removal / Services provided to prevent removal / Reason for services provided to prevent placement

Summary of Family’s Strengths and Weaknesses:

Characteristic / Strength / Weakness / Comment
Financial Status
Housing
Transportation
Extended Family Support
Community Support
Willing to work with Agency
Desires to change
Recognition of problem
Attitude about parenting
Marital Relationship
Sibling Relationships
Parent/Child Relationships
Health
Mental Health
Intelligence
Education/Training
Other

Problem Statement:

1. Family’s perception of problem:

1. Family’s attempt at problem resolution:

1. List of problems which constitute a threat to family functioning or a barrier to the child remaining in the home or returning home:

1. List of goals for improved family functioning and elimination of problems which create barriers to the child living at home:

1. E: Summary of services to be provided and the reason each service is needed:

1. Are these services necessary to prevent family dysfunction and to eliminate the threat of out-of-state placement for children:

FBS Staff: ______

Date: ______