ADT CPS Assessment for Abuse or Neglect



-504825-247650ADT CPS Assessment for Abuse/Neglect00ADT CPS Assessment for Abuse/NeglectIntake ID: Case: (Case Name) Individual: Case Number: Case Name: Assessment Number: Section 1: Allegation/Concern Summary of current allegations/Type of maltreatment alleged:Section 2: Referral Members Section 3: Referral FindingsVictim NamePerp NameResultUnder AppealSection 4: AssessmentChild/Youth Assessment Interview Interview FORMCHECKBOX Refused to be interviewed FORMCHECKBOX Unable to be interviewedNative American FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Yes FORMCHECKBOX Declined to disclose Child Physical/Mental Health (check all that apply) Risk Factors FORMCHECKBOX Hearing or vision impaired FORMCHECKBOX History of seizures FORMCHECKBOX Medical diagnosis requiring life sustaining measure FORMCHECKBOX Medical diagnosis requiring ongoing care FORMCHECKBOX Medical issues (asthma, broken arm, severe allergy) FORMCHECKBOX Mental health diagnosis ongoing medications FORMCHECKBOX Physical disability FORMCHECKBOX Requires psychotropic meds to function FORMCHECKBOX No Risk FactorsProtective Factors FORMCHECKBOX No physical/mental health issues FORMCHECKBOX Received care for identified mental health issues FORMCHECKBOX Receives care for identified medical issues FORMCHECKBOX Up to date on immunizationsChild Development/Education (check all that apply) Risk Factors FORMCHECKBOX Developmentally delayed FORMCHECKBOX Difficulty communicating needs FORMCHECKBOX Educationally delayed/IEP not utilized FORMCHECKBOX Is not potty trained or unable to use toilet FORMCHECKBOX Lack of muscle control, motor skills FORMCHECKBOX Limited verbal ability or non-verbal FORMCHECKBOX Non-mobile or limited mobility FORMCHECKBOX Not attached to adult caregiver FORMCHECKBOX Poor social skills/peer relations FORMCHECKBOX Requires assistance for dressing/bathing FORMCHECKBOX No risk factorsProtective Factors FORMCHECKBOX Able to dress/bath self FORMCHECKBOX Child receiving services for delay FORMCHECKBOX Developmentally on track FORMCHECKBOX Educationally on track FORMCHECKBOX Good social skills/peer relations FORMCHECKBOX Secure attachment to adult caregiverChild Behaviors (check all that apply)Risk Factors FORMCHECKBOX Alcohol use/abuse FORMCHECKBOX AWOL history/risk FORMCHECKBOX Bullying FORMCHECKBOX Can’t focus/hyperactive FORMCHECKBOX Destruction of property FORMCHECKBOX Doesn’t follow rules/oppositional FORMCHECKBOX Drug use/abuse FORMCHECKBOX Encopresis/enuresis not due to age FORMCHECKBOX Escalating negative behaviors FORMCHECKBOX Expulsion/suspensions from school FORMCHECKBOX Fire setting FORMCHECKBOX Gang involvement FORMCHECKBOX Has harmed self or others FORMCHECKBOX Past victim of abuse/neglect FORMCHECKBOX Previous juvenile court involvement FORMCHECKBOX Rages/tantrums FORMCHECKBOX Requires extensive supervision FORMCHECKBOX Sexually reactive/Sexually acting out FORMCHECKBOX Sexually active FORMCHECKBOX Threatens to harm self or others FORMCHECKBOX Torturing/killing small animals FORMCHECKBOX Truancy/ skipping school FORMCHECKBOX No Risk FactorsProtective Factors FORMCHECKBOX Behavioral issues within normal range for child’s age FORMCHECKBOX Child is responding to services provided FORMCHECKBOX Receives services for identified behavioral indicatorsDescribe child and any factors that need further explanation:MaltreatmentInjuries/ConditionsCheck all that applyChild’s injuries/conditions as a result of abuse/neglect (select all that apply) FORMCHECKBOX Observable injury FORMCHECKBOX Internal injury FORMCHECKBOX Injured in a critical area of the body FORMCHECKBOX Emotional injury as documented by a QMHP FORMCHECKBOX Has a sexually transmitted disease FORMCHECKBOX Sexually abused FORMCHECKBOX Abuse/neglect did not result in injury FORMCHECKBOX Child had no maltreatment FORMCHECKBOX No issuesDescribe injury/condition in specific terms (size, shape, location, color, impact of abuse):Did the child receive medical treatment or evaluation during this investigation/assessment (select all that apply) FORMCHECKBOX EMS FORMCHECKBOX General Practitioner FORMCHECKBOX Child Advocacy Center FORMCHECKBOX ER/urgent care FORMCHECKBOX Local hospital FORMCHECKBOX Mental health evaluations FORMCHECKBOX No medical evaluation/treatment FORMCHECKBOX PediatricianNeglect (Check all that apply)Hygiene/clothing FORMCHECKBOX Clothing does not protect from elements FORMCHECKBOX Illness or exposure due to clothes FORMCHECKBOX Regularly wears soiled clothes FORMCHECKBOX Repeated infestations of lice/bedbugs FORMCHECKBOX No issues Food FORMCHECKBOX Dehydration FORMCHECKBOX Dietary needs not met FORMCHECKBOX Feeding children non-human food items FORMCHECKBOX Food poisoning FORMCHECKBOX Malnourished FORMCHECKBOX Symptoms of failure to thrive FORMCHECKBOX No issues Educational (Check all that apply) FORMCHECKBOX Numerous unexcused absences FORMCHECKBOX No issuesExploitation FORMCHECKBOX Engages child in criminal activities FORMCHECKBOX Uses child’s financial resources for personal gain FORMCHECKBOX Victim of Human Trafficking FORMCHECKBOX No issuesMedical (Check all that apply) FORMCHECKBOX Failure to seek medical attention FORMCHECKBOX Life threatening unmet health needs FORMCHECKBOX Unmet health needs may have long term effects FORMCHECKBOX No issuesRisk of Harm (Check all that apply)Risk of Physical Abuse FORMCHECKBOX Child has fear of caretaker FORMCHECKBOX Caretaker has caused death/serious injury to a child FORMCHECKBOX Child exposed to bizarre forms of punishment FORMCHECKBOX No issuesRisk of Sexual Abuse FORMCHECKBOX Caretaker has previous sex abuse finding or conviction FORMCHECKBOX Child exhibiting physical/ behavioral indicators of sexual abuse FORMCHECKBOX Child unsupervised with person listed on the sex offender registry FORMCHECKBOX No issuesRisk of General Harm (Check all that apply) FORMCHECKBOX Caretaker has a prior involuntary TPR on another child FORMCHECKBOX Caretaker self-reports inability to cope FORMCHECKBOX Caretaker self-reports they may harm child FORMCHECKBOX Child allowed to use drugs and/or alcohol FORMCHECKBOX Child born exposed to drugs and/or alcohol FORMCHECKBOX Child or family member threaten with a weapon FORMCHECKBOX DV related incidents are more severe/frequent FORMCHECKBOX Parent’s cannot meet own needs FORMCHECKBOX Per court order, caretaker does not have custody of child FORMCHECKBOX Sibling of a child fatality/near fatality victim FORMCHECKBOX Violation of EPO/DVO puts child in danger FORMCHECKBOX No issuesMaltreatment/neglect description Adult Assessment (Complete for each adult)InterviewInterview Native American FORMCHECKBOX Refused to be interviewed FORMCHECKBOX Unable to be interviewed FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX Yes FORMCHECKBOX Declined to disclose Adult Health and FunctioningRisk Factors FORMCHECKBOX Alcohol abuse FORMCHECKBOX Attention seeking FORMCHECKBOX Dishonest and/or manipulative FORMCHECKBOX Disregard for others’ safety or wellbeing FORMCHECKBOX Drug abuse FORMCHECKBOX Hostile to authority figures or service providers FORMCHECKBOX Impulsive or unpredictable FORMCHECKBOX Intellectual or cognitive disability FORMCHECKBOX Irrational or disconnected from reality FORMCHECKBOX Lacks insight into their own behavior FORMCHECKBOX Mental health issue that affects functioning FORMCHECKBOX Paranoid FORMCHECKBOX Physical disability or debilitating illness FORMCHECKBOX Selfish, self-centered decision-making FORMCHECKBOX Unable to apply logic to solve problems FORMCHECKBOX Unable to assess (due to inability to interview) FORMCHECKBOX Victim of domestic violence FORMCHECKBOX No Risk FactorsProtective Factors FORMCHECKBOX Accepts assistance that enhances functioning FORMCHECKBOX Candid and/or cooperative FORMCHECKBOX Copes or functions despite a disability FORMCHECKBOX Demonstrates logic/reasoning ability FORMCHECKBOX No mental health issues FORMCHECKBOX No physical health issues FORMCHECKBOX Primary relationships are stable FORMCHECKBOX Realistic awareness of self and reality FORMCHECKBOX Respects the rights and feeling or others FORMCHECKBOX Seeks and give affection to loved onesAbility to Manage Daily Life and Stress (High Risk Behaviors) Risk Factors FORMCHECKBOX Abuses substances (drugs/alcohol to escape or deal with stress FORMCHECKBOX Blames others for problems FORMCHECKBOX Displays of frustration/anger cause injury or likelihood of harm FORMCHECKBOX Displays of frustration/anger out of proportion to situation FORMCHECKBOX Escalating frustration/anger FORMCHECKBOX Lack of realistic long term goals FORMCHECKBOX Overwhelmed/discouraged by responsibilities FORMCHECKBOX Parasitic lifestyle: relies on others to provide food, housing, etc. FORMCHECKBOX Poor self-control FORMCHECKBOX Rapidly changing affect or emotional displays FORMCHECKBOX Serial relationships FORMCHECKBOX Unable or unwilling to plan ahead FORMCHECKBOX Unable to assess (due to inability to interview) FORMCHECKBOX Unstable/chaotic relationships FORMCHECKBOX No Risk FactorsProtective Factors FORMCHECKBOX College or career training FORMCHECKBOX Healthy support network FORMCHECKBOX High school education or GED FORMCHECKBOX Realistic coping strategies FORMCHECKBOX Realistic understanding of barriers FORMCHECKBOX Realistic view of daily needs/obligations FORMCHECKBOX Self-sufficient, able to meet own needsMethods of behavior management Risk Factors FORMCHECKBOX Can’t articulate discipline strategies FORMCHECKBOX Can't articulate how to manage beyond control behaviors FORMCHECKBOX Can’t articulate how to manage tantrums, rages FORMCHECKBOX Inconsistant discipline FORMCHECKBOX Methods of discipline result in injury to child FORMCHECKBOX Severe or harsh discipline FORMCHECKBOX Unable to assess (due to inability to interview) FORMCHECKBOX Unable to manage child’s behavior FORMCHECKBOX Unusual/bizarre discipline FORMCHECKBOX Uses no discipline or fails to follow throughProtective Factors FORMCHECKBOX Balances teaching and discipline FORMCHECKBOX Discipline techniques corroborated by collaterals FORMCHECKBOX Uses age appropriate discipline FORMCHECKBOX Willingness to learn appropriate discipline techniques FORMCHECKBOX No Risk FactorsAttitude Toward Caretaking Risk Factors FORMCHECKBOX Articulates inappropriate expectations for child FORMCHECKBOX Caretaker self-reports may harm child FORMCHECKBOX Describes child in negative terms FORMCHECKBOX Doesn’t follow through with required medical treatment FORMCHECKBOX Fails to protect child FORMCHECKBOX Fails to supervise child FORMCHECKBOX Frustrated by parenting duties FORMCHECKBOX Inability to recognize situational risks to child FORMCHECKBOX Not attached to the child FORMCHECKBOX Puts personal needs before child FORMCHECKBOX Unable to assess (due to inability to interview) FORMCHECKBOX Uses poor judgment in choosing caregivers FORMCHECKBOX No Risk FactorsProtective Factors FORMCHECKBOX Attached to the child FORMCHECKBOX Demonstrates cooperation with child’s service providers FORMCHECKBOX Has realistic expectations of child FORMCHECKBOX Meets child’s needs FORMCHECKBOX Parent seeks and follows medical advice FORMCHECKBOX Prioritizes the child’s safety FORMCHECKBOX Receives satisfaction being a parent FORMCHECKBOX Recognizes dangerous situationsCPS/APS/Criminal History Risk Factors FORMCHECKBOX Adult is registered sex offender FORMCHECKBOX Parental rights on a child involuntarily terminated FORMCHECKBOX Prior convictions involving drugs/alcohol FORMCHECKBOX Criminal “versatility”: variety of types of convictions FORMCHECKBOX Prior felony convictions involving weapon/violence FORMCHECKBOX Prior reports of domestic violence FORMCHECKBOX Prior revocation of parole/probation FORMCHECKBOX Prior substantiated reports FORMCHECKBOX Prior substantiation death/near death of another child FORMCHECKBOX Action or lack of action contributed to death/serious harm of a child FORMCHECKBOX Multiple prior reports not accepted for investigation FORMCHECKBOX Prior unsubstantiated reports FORMCHECKBOX No Risk FactorsProtective Factors FORMCHECKBOX Acknowledges responsibility for prior charges FORMCHECKBOX Acknowledges responsibility for child welfare allegations FORMCHECKBOX No criminal charges FORMCHECKBOX No felony convictions FORMCHECKBOX No prior CPS/APS history FORMCHECKBOX Non-violent/traffic offenses FORMCHECKBOX Other rehabilitative services FORMCHECKBOX Received treatment/rehabilitative services related to prior sexual abuseNotesFamily FunctioningIs the home a health or safety hazard for the individuals living there? FORMCHECKBOX Broken windows FORMCHECKBOX Dangerous animals in the home FORMCHECKBOX Dangerous chemicals accessible FORMCHECKBOX Exposed wiring FORMCHECKBOX Fire safety hazards FORMCHECKBOX Hoarding FORMCHECKBOX Holes in floor or walls FORMCHECKBOX Human/animal feces FORMCHECKBOX Inadequate heat in winter FORMCHECKBOX Infestation of rodents/insects FORMCHECKBOX Inoperable sanitation FORMCHECKBOX Insufficient shelter (includes homeless) FORMCHECKBOX Medications not secure FORMCHECKBOX Meth lab FORMCHECKBOX Mold infestation FORMCHECKBOX Spoiled food FORMCHECKBOX Unsafe space heaters FORMCHECKBOX Unsupervised with loaded guns/weapons FORMCHECKBOX No issuesWhat corrective action has caretaker made for any checked item? Do you have any current concerns that the child(ren) are not supervised adequately? FORMCHECKBOX Caretaker is unqualified or lacks capacity to meet child’s needs FORMCHECKBOX Child afraid to be alone FORMCHECKBOX Child requires more supervision than parents are providing FORMCHECKBOX Child unsupervised with individual where there is a no contact order FORMCHECKBOX Children do not know what to do in case of emergency FORMCHECKBOX Expulsion of child from the home FORMCHECKBOX Left alone in a vehicle FORMCHECKBOX Medical/QMHP expresses concern that caretaker use of alcohol/drugs/medications impairs their ability to take care of child FORMCHECKBOX Parent’s whereabouts are not known FORMCHECKBOX Unsupervised child 7 y/o or younger(developmental/chronological) FORMCHECKBOX Abusing drugs/alcohol or incapacitated while caring for child FORMCHECKBOX No issues found during investigationPlease explain your current concerns regarding supervision of the child(ren):Family Structure (check all that apply) FORMCHECKBOX Blended family FORMCHECKBOX Married couple FORMCHECKBOX Multiple families in home FORMCHECKBOX Multiple generations in the home FORMCHECKBOX Single parent FORMCHECKBOX Unmarried couple/Domestic partnershipFamily Developmental Stage FORMCHECKBOX Infant/preschool children FORMCHECKBOX School age children FORMCHECKBOX Teenage children FORMCHECKBOX Adult childrenFamily Functioning /Culture FORMCHECKBOX Adult was in out of home care as a child FORMCHECKBOX Adult was exposed to domestic violence as a child FORMCHECKBOX Caregiver history of childhood abuse/neglect FORMCHECKBOX Caregiver, active military FORMCHECKBOX Caregiver, inactive military FORMCHECKBOX Disregard for education FORMCHECKBOX Escalating pattern of child maltreatment FORMCHECKBOX Frequent changes in residence FORMCHECKBOX Home setting, urban/suburban FORMCHECKBOX Inconsistent family boundaries FORMCHECKBOX Mistrust of medical providers/ government FORMCHECKBOX Native American heritage/belongs to a tribe FORMCHECKBOX Parent/child role confusion FORMCHECKBOX Relocated to US during FORMCHECKBOX Social or geographic isolation FORMCHECKBOX Strict gender rolesFamily Use of Supports (Check all that apply)Community FORMCHECKBOX Unwilling to utilize/access FORMCHECKBOX Unaware but willing to access FORMCHECKBOX Aware and can access FORMCHECKBOX Utilizing available supports FORMCHECKBOX Isolated from supports FORMCHECKBOX No supports identified or availableFamily/Friends FORMCHECKBOX Unwilling to utilize/access FORMCHECKBOX Unaware but willing to access FORMCHECKBOX Aware and can access FORMCHECKBOX Utilizing available supports FORMCHECKBOX Isolated from supports FORMCHECKBOX No appropriate supports identified or available Family Functioning NotesChronology InformationInvestigative Related DataReport received:Assigned by Supervisor:Inv Worker Received Report: First Attempt to Make Contact:First Face to Face Contact Made with Victim:First FSOS Consultation: mm/dd/yyyymm/dd/yyyymm/dd/yyyymm/dd/yyyymm/dd/yyyymm/dd/yyyyRoles of Individuals Interviewed FORMCHECKBOX Alleged Perpetrator FORMCHECKBOX Alleged Victim FORMCHECKBOX Attorney FORMCHECKBOX Clergy FORMCHECKBOX Custodial Parent FORMCHECKBOX Day Care Provider FORMCHECKBOX Employer FORMCHECKBOX EMS/Fire Department FORMCHECKBOX Former Spouse FORMCHECKBOX Family Friend FORMCHECKBOX Family Support/Kames FORMCHECKBOX Forensic Consultation FORMCHECKBOX Household Member-Related FORMCHECKBOX Household Member Non-Related FORMCHECKBOX Landlord FORMCHECKBOX Law Enforcement FORMCHECKBOX Medical Provider FORMCHECKBOX Mental Health Provider FORMCHECKBOX Neighbor FORMCHECKBOX Non-Custodial Parent FORMCHECKBOX Paramour/Partner FORMCHECKBOX Relative FORMCHECKBOX School Personnel FORMCHECKBOX No collateral contact FORMCHECKBOX SpouseEvidence Collected FORMCHECKBOX Child Care Provider records FORMCHECKBOX Court records FORMCHECKBOX Law Enforcement records FORMCHECKBOX Drug Screen FORMCHECKBOX Medical records FORMCHECKBOX Mental Health records FORMCHECKBOX Other CPS agency records FORMCHECKBOX Photographs FORMCHECKBOX School records FORMCHECKBOX Substance abuse assessmentInvestigation narrative:Incident resultsMaltreatment FactorsMental HealthFamily ViolenceSubstance Abuse FORMCHECKBOX Directly Contributed FORMCHECKBOX Directly Contributed FORMCHECKBOX Directly Contributed FORMCHECKBOX Indirectly Contributed FORMCHECKBOX Indirectly Contributed FORMCHECKBOX Indirectly Contributed FORMCHECKBOX Was a Risk Factor FORMCHECKBOX Was a Risk Factor FORMCHECKBOX Was a Risk Factor FORMCHECKBOX Not Applicable FORMCHECKBOX Not Applicable FORMCHECKBOX Not ApplicablePhysical Abuse (Check all that apply)Severity 4 FORMCHECKBOX Inflicted injury to a child 4 years or younger FORMCHECKBOX Assault of a child 4 years or younger (including a child injured in a DV incident) FORMCHECKBOX Inflicted injury to a non-mobile child of any age FORMCHECKBOX Bizarre or cruel discipline including restraints, i.e. binding child to chair or locking in a closetSeverity 3 FORMCHECKBOX Inflicted injury to a critical area of the body in a child 5 years or younger FORMCHECKBOX Assault of any child 12 years or younger (including physical altercation between a child and caregiver) FORMCHECKBOX Method of discipline is excessive or includes threats of harmSeverity 2 FORMCHECKBOX Physical altercation between parent/caretaker and child 13 years or youngerSeverity 0 FORMCHECKBOX NoneSexual Abuse (Check all that apply)Severity 4 FORMCHECKBOX Sexual abuse or sexual exploitation of a child FORMCHECKBOX Child with a sexually transmitted diseaseSeverity 3 FORMCHECKBOX Adults exposing child to sexual activity or pornography FORMCHECKBOX Adults exposing their private parts to a childSeverity 0 FORMCHECKBOX NoneMedical (Check all that apply)Severity 4 FORMCHECKBOX Child with life threatening unmet health needsSeverity 3 FORMCHECKBOX Unmet health needs may result in future health problems or have cause long term effectsSeverity 2 FORMCHECKBOX Failure to seek medical attention or lack of follow up for non-life threatening situationsSeverity 0 FORMCHECKBOX NoneSupervision (Check all that apply)Severity 4 FORMCHECKBOX Abandonment of any child (including parent incapacitated due to drugs or alcohol) FORMCHECKBOX Unsupervised child 7 and under (chronological or developmental)Severity 3 FORMCHECKBOX Child ages 8-12 unsupervised for extended periods of time FORMCHECKBOX Parent’s chronic use of drug/alcohol renders them incapable of caring for childSeverity 2 FORMCHECKBOX Child age 13-15 unsupervised for extended periods of time (consider developmental age of child) FORMCHECKBOX Child allowed to have inappropriate sexual relationshipsSeverity 1 FORMCHECKBOX Child left with family/caretaker with no provisions for making educational or medical decisions and no way to contact parent FORMCHECKBOX Caretaker fails to make reasonable efforts to get child to schoolSeverity 0 FORMCHECKBOX NoneNeglect (Check all that apply)Severity 4 FORMCHECKBOX Extreme hazardous environment FORMCHECKBOX Malnutrition and dehydration due to neglectSeverity 3 FORMCHECKBOX Insufficient shelter (living in care, under a bridge, in a barn, tent, etc.) FORMCHECKBOX Child’s special dietary needs are not being met resulting in health issuesSeverity 2 FORMCHECKBOX Home has trash or clutter creating fire hazard, unsecured/exposed chemicals, medications or other hazards FORMCHECKBOX Child age 0-7 dressed inappropriately for weather conditions resulting in health issues for child FORMCHECKBOX Financial exploitation to provide financial or material gain for the adult FORMCHECKBOX Poor hygiene in children 0-7 that has negative impact on the child’s health or emotional well-beingSeverity 1 FORMCHECKBOX Home with inadequate heat, food, home cluttered, dirty dishes, etc. FORMCHECKBOX Parent has failed to follow through with getting rid of head lice FORMCHECKBOX Poor hygiene for children age 8 and older that has negative impact on the child’s health or emotional well-beingSeverity 0 FORMCHECKBOX NoneRisk of harm (Check all that apply)Severity 4 FORMCHECKBOX Previous child death/near death (due to abuse/neglect or unexplained/undetermined causes) FORMCHECKBOX Child involved in a DV incidentSeverity 3 FORMCHECKBOX Child forced/allowed to engage in a criminal activity, exposed to the distribution of drugs or criminal activity by the parent FORMCHECKBOX Child ages 12 and younger allowed to use drugs/alcoholSeverity 2 FORMCHECKBOX Child 13 y/p and older allowed to engage in criminal activity including drugs/alcoholSeverity 0 FORMCHECKBOX NoneEmotional (Check all that apply)Severity 3 FORMCHECKBOX Qualified mental health professional has found emotional injurySeverity 0 FORMCHECKBOX NoneWhat broke down in the family that led to the abuse/neglect? Assessment ResultsRisk FactorsBased on your observations, interviews and information collected during this assessment, please rate the following:The most vulnerable child in the family (considering age, development and behavioral needs) (select only one): FORMCHECKBOX Not vulnerable-behaviors within normal range, child attached to caregiver, developmentally on track, able to complete tasks of daily living (bathing, feeding, dressing) FORMCHECKBOX Mild-has behaviors that are controlled by medication or therapy, struggles with some subjects in school, can usually complete tasks of daily living without assistance FORMCHECKBOX Moderate-often has problematic behaviors that interfere with functioning, can generally communicate needs, mild developmental delays, requires assistance with tasks of daily living FORMCHECKBOX Severe-physical or mental illness that requires intensive treatment, behaviors are out of control, difficulty in communication needs FORMCHECKBOX Extremely vulnerable-physical disability requiring life sustaining care, not attached to caregiver, non-mobile or very limited mobility, nonverbal, unable to complete tasks of daily livingThe primary caregiver’s ability to manage daily life/stress and attitude toward caregiving (select only one): FORMCHECKBOX No concerns-Satisfied being a parent, balances teaching with discipline, realistic coping strategies, and healthy support system FORMCHECKBOX Mild-Mostly satisfied with parent/caretaker role, has some community/family supports FORMCHECKBOX Moderate-Sometimes uses positive methods to deal with conflict, Physical or mental impairment limits ability but accepts assistance, Inconsistent in providing basic care, nurturing and/or support FORMCHECKBOX Severe-Non-offending parent does not believe maltreatment occurred, has unstable relationships, relies on others to meet children’s needs, overwhelmed by responsibilities, unable/unwilling to plan ahead, unsatisfied with parent/caretaker role FORMCHECKBOX Extreme concerns-Puts perpetrator needs before family’s needs, fails to supervise the child, not attached or describes the child in negative terms, inability to recognize risks to the child, very dissatisfied with parent/caretaker roleThe perpetrator’s access to the child and high risk patterns/behaviors (select only one): FORMCHECKBOX No concerns-Verified no perpetrator access, No threats/use of violence, recognizes/manage threats/dangers to child, identifies high risk times and appropriate responses FORMCHECKBOX Mild-Limited perpetrator access, situational stress-linked to services to manage, usually can verbalize high-risk times/trigger-respond appropriately, problem-solving skills can be increased with supports; First occurrence-parent is remorseful FORMCHECKBOX Moderate-Limited self-control in caretaking or disciplining-no injury, Alcohol/Drug abuse (including prescription drug) impacts caretaking, Unrealistic expectations based on the child’s strengths/limitations, history of violence FORMCHECKBOX Severe-Uses threats to manage conflict, Incapacitated from drugs/alcohol, unable to verbalize high-risk times/triggers, History of intergenerational family violence, criminal charges FORMCHECKBOX Extreme concerns-Child resides with perpetrator, Actions resulted in serious physical injury, Expresses fear they will harm child, Parent justify maltreatment as cultural/religious practice, Previous involuntary TPR, Perpetrator unknownOutcomePlan FORMCHECKBOX Close Referral FORMCHECKBOX Prevention Plan FORMCHECKBOX In home ongoing case FORMCHECKBOX Out of home ongoing case FORMCHECKBOX Aftercare PlanAssessment Conclusion ................
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