ࡱ> q` ƵbjbjqPqP :::Oeeef h:kh8}d}}}~~~RTTTTTT$-hx5~~~~~x}}~ }}R~R0f}k t=oe$ê0B$__Hf_f0~~~~~~~xx)~~~~~~~]ee SAFE Child Specific Home Study Report This home study was completed by  FORMTEXT Name of Public/Private Agency to consider the placement of a specific child or specific children with the applicants for the purpose of either relative or foster care placement, Legal Guardianship and/or adoption. Name of Family:  FORMTEXT      Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT   Postal Code:  FORMTEXT 00000 -  FORMTEXT 0000Home Phone:  FORMTEXT      Cell Phone:  FORMTEXT       APPLICATION DISPOSITION The Applicants have applied specifically to become  FORMDROPDOWN  for  FORMTEXT Name(s) of Child(ren). Home Study Application received on: FORMTEXT      Certified for Foster Placement on: FORMTEXT      Approved for Adoptive Placement on: FORMTEXT      Home Study completed on:  FORMTEXT       APPLICANT INFORMATION  FORMTEXT Applicant's Full Name FORMTEXT Applicant's Full NameDate of Birth: FORMTEXT      Date of Birth: FORMTEXT      Birthplace: FORMTEXT      Birthplace: FORMTEXT      Gender: FORMTEXT      Gender: FORMTEXT      Religion: FORMTEXT      Religion: FORMTEXT      Occupation: FORMTEXT      Occupation: FORMTEXT      Language(s): FORMTEXT      Language(s): FORMTEXT      Education: FORMTEXT      Education: FORMTEXT      Height: FORMTEXT      Height: FORMTEXT      Weight: FORMTEXT      Weight: FORMTEXT      Hair: FORMTEXT      Hair: FORMTEXT      Eyes: FORMTEXT      Eyes: FORMTEXT      Date of health questionnaire/report:  FORMTEXT      Date of health questionnaire/report:  FORMTEXT      TB test results: FORMDROPDOWN TB test results: FORMDROPDOWN  MARITAL INFORMATION Date of Marriage:  FORMTEXT      Marriage Verification:  FORMDROPDOWN Place of Marriage:  FORMTEXT       DATES OF CONTACT Date Individual/Couple Location  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       CHILD OR YOUTH BEING CONSIDERED FOR PLACEMENT  FORMTEXT Provide the Name(s), DOB, gender, reason for protective custody and legal status of the child(ren) or youth(s) being considered, e.g., reunification, reunification terminated, TPR hearing pending, freed for adoption, etc.  FORMTEXT If the child(ren) or youth(s) is/are currently placed in the home, discuss their adjustment since placement. If not currently placed with the applicants, discuss the nature and character of the applicants' relationship(s) with the child(ren) or youth(s).  FORMTEXT Describe the strengths, personality, interests and emotional/physical development of each child or youth being considered. Discuss the level of understanding each child/youth has about such issues as reunification,maintaining connections, adoption, etc.   FORMTEXT Identify and take into account the special considerations noted on the SAFE Matching inventory, e.g. placement with siblings, special diet, accommodations for a physical disability, maintain connections with birth family, needs a stay-at-home parent, etc.  FORMTEXT Describe the challenging child/youth issues identified on the SAFE Matching Inventory, e.g., difficult temperament, problematic behaviors, attachment issues,etc. Indicate whether or not therapeutic services are being used or are needed. MOTIVATION  FORMTEXT Provide the Applicants' stated reasons for wanting the child(ren) placed with them and the parenting responsibilities they are willing to assume, e.g., foster parent, legal/risk parent, apdoptive parent or shelter parent. HOME ENVIRONMENT Type of Residence: FORMTEXT House, Apt, Condo, Etc.Square Footage: FORMTEXT      Bedrooms: FORMTEXT      Bathrooms: FORMTEXT      Length of Time in Current Residence: FORMTEXT        FORMTEXT Describe general characteristics of the Applicants' home and neighborhood. Indicate the type of residence (house, apartment, condo, etc.) and square footage. Describe the floor plan including the number of bedrooms and bathrooms.  FORMTEXT Describe the yard space and indicate if there is a pool or spa. Describe the sleeping arrangements and also indicate whether or not there are guns or pets in the home.  The interior and exterior of the home was inspected for health and safety hazards. The inspection was completed on  FORMTEXT      . FAMILY Applicant #1 -  FORMTEXT Applicant's full name  FORMTEXT Describe how the applicant presents him/her self. Also indicate any special interests, hobbies, expertise or talents the applicant possesses.  FORMTEXT Identify parents, siblings, their location and circumstances plus type and frequency of contact.  FORMTEXT Indicate name(s) and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated, e.g., death, divorce, annulment, breakup. Identify any children born of these unions and describe their current situation. Applicant #2 -  FORMTEXT Applicant's full name  FORMTEXT Describe how the applicant presents him/her self. Also indicate any special interests, hobbies, expertise or talents the applicant possesses.  FORMTEXT Identify parents, siblings, their location and circumstances plus type and frequency of contact.  FORMTEXT Indicate name(s) and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated, e.g., death, divorce, annulment, breakup. Identify any children born of these unions and describe their current situation. Applicants Sons and Daughters  FORMTEXT Indicate "None" or provide name(s), DOB and gender. Describe their personality, interests, school or occupational situation, general health and living situation.  Other Children or Youth living or frequently in the home  FORMTEXT Indicate "None" or provide name(s), DOB, gender. Provide description of their personality, interests, school report information if any, general health. Indicate the nature of their relationship to the Applicants and living situation. Other adults residing or frequently in the home  FORMTEXT Indicate name of any adult who is living in the home or who is in the home on a regular basis. Describe the amount and type of contact they would have with a child or youth being considered.  FORMTEXT Indicate each individual's occupation, general health, TB results (if they live in the home) and the nature of their relationship to the Applicants. Family Lifestyle  FORMTEXT Describe current and proposed child care arrangements and work and non-work day routines and rituals.  FORMTEXT What are the basic household rules and expectations? Who does what in terms of chores, cooking, bill paying, home maintenance, transportation, etc.? Describe how the family deals with privacy and nudity in the home.  FORMTEXT What kind of recreational, social and religious activities does the family engage in? Does the family celebrate holidays; which ones and how are they spent? Previous adoption and/or foster care experience  FORMTEXT Indicate "None" or discuss the circumstances and the adjustment of the child(ren) or youth(s) to the family. FINANCES Combined annual gross earned income: $ FORMTEXT       Sources of additional income:  FORMTEXT Explain, if any CRIMINAL/CHILD ABUSE RECORD The required criminal record and Child Abuse Index checks were completed for  FORMTEXT Indicate the name(s) of any other individuals who were screened. Criminal History Repository:  FORMTEXT CHR Findings CANS:  FORMTEXT CANS Findings Other findings:  FORMTEXT Indicate FBI findings; DMV findings; local law enforcement check, or CPS service records. EMERGENCY CARE PLAN  FORMTEXT In case of an incapacitating illness or death of the Applicants, indicate whom the designated caretaker(s) will be and the nature of their relationship to the Applicants.  FORMTEXT Indicate if these arrangements have been discussed with the designated caretaker(s), how willing they are to assume this responsibility and whether arrangements have been formalized in a will or trust. CONTACT WITH FAMILY OF ORIGIN AND SIGNIFICANT OTHERS  FORMTEXT Describe the type of relationship and contact the Applicants are willing to have with the birth parents and other significant connections such as siblings, grandparents, foster parents, etc. Describe any written post-adoption contact agreement(s). REFERENCES  FORMTEXT Indicate if all references have been received. Summarize information provided. FAMILY PREPARATION AND TRAINING ACTIVITIES  FORMTEXT Identify and describe agency family preparation activities. Include Applicants' statements regarding their participation and benefits derived from these activities. LEGAL/FINANCIAL RIGHTS AND RESPONSIBILITIES  FORMTEXT Applicant's full name and  FORMTEXT Applicant's full name have been provided with information concerning the different roles, responsibilities, legal and financial rights and benefits of relative/fictive kin caregivers, foster parents, legal guardians and adoptive parents. Also, should they file a petition to adopt,  FORMTEXT       and  FORMTEXT       understand that they will be accepting full legal and financial parental responsibility for  FORMTEXT Name(s) of Child(ren) or /Youth(s) once an adoption is finalized. The agency s grievance review hearing procedures  FORMDROPDOWN  explained to the Applicants. PSYCHOSOCIAL INVENTORY RESULTS NOTE: Below is a list of the psychosocial factors found on the SAFE Psychosocial Inventory. Using the Psychosocial Inventory, each factor was considered and rated several times by the social worker during the course of this home study. The ratings below represent the final ratings. The ratings are defined as follows: 1 = an exceptional strength, 2 = a strength, 3 = an issue of concern, 4 = a major issue of concern and 5 = very serious problem. The OVERALL EVALUATION OF SECTION ratings reflect the degree to which all issues of concern identified in the section were either resolved, mitigated or the prognosis for change.#1#2HISTORY#1#2EXTENDED FAMILY RELATIONSHIPS FORMDROPDOWN  FORMDROPDOWN Childhood Family Adaptability FORMDROPDOWN  FORMDROPDOWN Extended Family Cohesion FORMDROPDOWN  FORMDROPDOWN Childhood Family Cohesion FORMDROPDOWN  FORMDROPDOWN Extended Family Adaptability FORMDROPDOWN  FORMDROPDOWN Childhood History of Deprivation/Trauma FORMDROPDOWN  FORMDROPDOWN Relationship with own Extended Family FORMDROPDOWN  FORMDROPDOWN Childhood History of Victimization FORMDROPDOWN  FORMDROPDOWN Relationship with Spouses/Partners Family FORMDROPDOWN  FORMDROPDOWN Adult History of Victimization/Trauma FORMDROPDOWN  FORMDROPDOWN OVERALL EVALUATION OF SECTION FORMDROPDOWN  FORMDROPDOWN History of Child Abuse/Neglect FORMDROPDOWN  FORMDROPDOWN History of Alcohol/Drug UsePHYSICAL/SOCIAL ENVIRONMENT FORMDROPDOWN  FORMDROPDOWN History of Crime/Arrest/Allegations/Violence FORMDROPDOWN Cleanliness/Orderliness/Maintenance FORMDROPDOWN  FORMDROPDOWN Psychiatric History FORMDROPDOWN Safety FORMDROPDOWN  FORMDROPDOWN Occupational History FORMDROPDOWN Furnishings FORMDROPDOWN  FORMDROPDOWN Marriage/Domestic Partner History FORMDROPDOWN Play Area/Equipment/Clothing FORMDROPDOWN  FORMDROPDOWN OVERALL EVALUATION OF SECTION FORMDROPDOWN Finances FORMDROPDOWN Support System#1#2PERSONAL CHARACTERISTICS FORMDROPDOWN Household Pets FORMDROPDOWN  FORMDROPDOWN Communication FORMDROPDOWN OVERALL EVALUATION OF SECTION FORMDROPDOWN  FORMDROPDOWN Commitment and Responsibility FORMDROPDOWN  FORMDROPDOWN Problem Solving#1#2GENERAL PARENTING FORMDROPDOWN  FORMDROPDOWN Interpersonal Relations FORMDROPDOWN  FORMDROPDOWN Child Development FORMDROPDOWN  FORMDROPDOWN Health and Physical Stamina FORMDROPDOWN  FORMDROPDOWN Parenting Style FORMDROPDOWN  FORMDROPDOWN Self-esteem FORMDROPDOWN  FORMDROPDOWN Disciplinary Methods FORMDROPDOWN  FORMDROPDOWN Acceptance of Differences FORMDROPDOWN  FORMDROPDOWN Child Supervision FORMDROPDOWN  FORMDROPDOWN Coping Skills FORMDROPDOWN  FORMDROPDOWN Learning Experiences FORMDROPDOWN  FORMDROPDOWN Impulse Control FORMDROPDOWN  FORMDROPDOWN Parental Role FORMDROPDOWN  FORMDROPDOWN Mood FORMDROPDOWN  FORMDROPDOWN Child Interactions FORMDROPDOWN  FORMDROPDOWN Anger Management and Resolution FORMDROPDOWN  FORMDROPDOWN Communication with Child FORMDROPDOWN  FORMDROPDOWN Judgment FORMDROPDOWN  FORMDROPDOWN Basic Care FORMDROPDOWN  FORMDROPDOWN Adaptability FORMDROPDOWN  FORMDROPDOWN Childs Play FORMDROPDOWN  FORMDROPDOWN OVERALL EVALUATION OF SECTION FORMDROPDOWN  FORMDROPDOWN OVERALL EVALUATION OF SECTIONMARITAL/DOMESTIC PARTNER #1#2SPECIALIZED PARENTINGRELATIONSHIP FORMDROPDOWN  FORMDROPDOWN Expectations FORMDROPDOWN Conflict Resolution FORMDROPDOWN  FORMDROPDOWN Effects of Abuse/Neglect FORMDROPDOWN Emotional Support FORMDROPDOWN  FORMDROPDOWN Effects of Sexual Abuse FORMDROPDOWN Attitude toward Spouse/Partner FORMDROPDOWN  FORMDROPDOWN Effects of Separation and Loss FORMDROPDOWN Communication between Couple FORMDROPDOWN  FORMDROPDOWN Structure FORMDROPDOWN Balance of Power FORMDROPDOWN  FORMDROPDOWN Therapeutic/Educational Resources FORMDROPDOWN Stability of the Marriage or Partnership FORMDROPDOWN  FORMDROPDOWN Birth Sibling Relationships FORMDROPDOWN Sexual Compatibility FORMDROPDOWN  FORMDROPDOWN Child Background Information FORMDROPDOWN OVERALL EVALUATION OF SECTION FORMDROPDOWN  FORMDROPDOWN Birth Parent Issues FORMDROPDOWN  FORMDROPDOWN OVERALL EVALUATION OF SECTIONSONS/DAUGHTERS/OTHERS RESIDINGOR FREQUENTLY IN HOME#1#2ADOPTION ISSUES FORMDROPDOWN Minor Sons and Daughters FORMDROPDOWN  FORMDROPDOWN Infertility FORMDROPDOWN Minors Residing or Frequently in the Home FORMDROPDOWN  FORMDROPDOWN Telling Child about Adoption FORMDROPDOWN Adult Sons and Daughters FORMDROPDOWN  FORMDROPDOWN Openness in Adoption FORMDROPDOWN Adults Residing or Frequently in the Home FORMDROPDOWN  FORMDROPDOWN Adoptive Parent Status FORMDROPDOWN OVERALL EVALUATION OF SECTION FORMDROPDOWN  FORMDROPDOWN OVERALL EVALUATION OF SECTION PSYCHOSOCIAL EVALUATION REPORT HISTORY  FORMTEXT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and degree of resolution. PERSONAL CHARACTERISTICS  FORMTEXT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. MARITAL/DOMESTIC PARTNER RELATIONSHIP  FORMTEXT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. SONS/DAUGHTERS/OTHERS RESIDING OR FREQUENTLY IN THE HOME  FORMTEXT For each person identified in this section, provide full narration that relates to each of the Desk Guide examples for the rating given.  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PHYSICAL/SOCIAL ENVIRONMENT  FORMTEXT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. GENERAL PARENTING  FORMTEXT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. SPECIALIZED PARENTING  FORMTEXT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. ADOPTION ISSUES  FORMTEXT Describe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change. PSYCHOSOCIAL EVALUATION CONCLUSIONS  FORMTEXT Based on your Psychosocial Evaluation determinations, draw your conclusions about the Applicants' commitment, ability and readiness to parent. Cleary explain how a section with an Overall Evaluation of Section rating of 3, 4, or 5 will affect parenting.  FORMTEXT For families who participated in PRIDE Practice training, speak to the family's ability to meet the five PRIDE competencies below based on your psychosocial evaluation conclusions.  FORMTEXT Protecting and nurturing children:  FORMTEXT Meeting children's developmental needs and addressing developmental delays:  FORMTEXT Supporting relationships between children and their families:  FORMTEXT Connecting children to safe, nurturing relationships intended to last a lifetime:  FORMTEXT Working as a member of a professional team: PLACEMENT COMPATABILITY  FORMTEXT Discuss each child's or youth's goodness of fit with this family in the context of the applicants' competency to address each of the child/youth's specific needs and special considerations.  FORMTEXT Illuminate any special needs, considerations, characteristics, behaviors, conditions or issues of the child(ren) or youth(s) that the Applicants are uniquely qualified to address or unable to manage. RECOMMENDATION It is recommended that  FORMTEXT Applicant's full nameand  FORMTEXT Applicant's full name be  FORMDROPDOWN  for  FORMDROPDOWN  for  FORMTEXT Name(s) of Child(ren).  FORMTEXT Caseworker FORMTEXT Supervisor  FORMTEXT Title FORMTEXT TitleDate: FORMTEXT      Date FORMTEXT       Waiver Required?  FORMDROPDOWN  Type:  FORMDROPDOWN  Directors Approval:  FORMDROPDOWN  DCFS Administrator Approval:  FORMDROPDOWN  Additional Attachments  FORMTEXT Indicate "None" or list additional attachments. REVIEW OF HOME STUDY REPORT By signing below I acknowledge that I have read a copy of this report.  FORMTEXT Applicant's Full Name FORMTEXT Applicant's Full NameDate: FORMTEXT      Date FORMTEXT        چ  <=JK@AIJjkL`L<=>HIJHIKLVWX  >?ABLMNϵϦϙϊ{ljh*BCJUaJjh*BCJUaJji h*BCJUaJh*BCJOJQJ\aJj h*BCJUaJj1 h*BCJUaJh*B5CJ\aJh*BCJaJh*BCJaJmHnHujh*BCJUaJjh*BCJUaJ*GHJKUVWhiklvwx?@ABCRjkuvwxjh*BCJUaJh*B5CJOJQJaJjh*BCJUaJjh*BCJUaJh*B5CJ\aJh*Bjh*BCJUaJh*BCJaJmHnHujh*BCJUaJjh*BCJUaJh*BCJaJ-kABCRS     :$If]:L`L ǎȎɎΎώݎގߎ  )*+,6ſſſſſōſπyjjhh*BCJUaJ h*B\aJh*B5CJOJQJaJh*BCJmHnHujh*BCJUjoh*BCJUjh*BCJU h*BCJjh*BCJUh*BCJaJh*BCJaJmHnHujh*BCJUaJj7h*BCJUaJ#+EfXG$:$If]:^a$:$If]:^kd$$Iflֈ%&@,4 la678BCFGQRSXYZ[efglmuv  024>@jlϱϢρrjh*BCJUaJj|h*BCJUaJ"jh*BCJUaJmHnHujh*BCJUaJj;h*BCJUaJjh*BCJUaJh*BCJaJh*BCJaJmHnHujh*BCJUaJjh*BCJUaJ(EFZnouI? :$If]:Lkd$$Ifl0&%4 la:$If]:^:$If]:^Lkdd$$Ifl0&%4 lauBDFHOMG kd$$IflֈX&  4 la :$If]: $:$If]:a$  JLhjlnV  68:<Pܾܱܢ܈}qbj=#h*BCJUaJh*BCJOJQJaJh*B5CJ\aJh*B>*CJOJQJaJh*BCJaJmHnHujI!h*BCJUaJh*B5CJOJQJaJj h*BCJUaJj% h*BCJUaJh*BCJaJjh*BCJUaJjUh*BCJUaJ"npV :$If]:L`L2kd"$$Iflr''4 la $$Ifa$  :kZI$:$If]:^a$$:$If]:^a$kd`"$$Iflֈ%&@,4 laPRT~ȓʓޓ ϟϛ}}sih*BCJOJQJh*BCJOJQJ h*B0Jjh*B0JUUh5Ejh5EUh*Bj%h*BCJUaJ"jh*BCJUaJmHnHuj'%h*BCJUaJh*BCJaJh*BCJaJmHnHujh*BCJUaJj#h*BCJUaJ$ȓuhh $:$If]:a$7kd$$$Ifl4&'4 laf4 :$If]:Gkde$$$IflF0&%4 la kiiiiiiiiiikd%$$IflֈX&  4 la   PAGE  Structured Analysis Family Evaluation (SAFE) Nevada Couple Child Specific Home Study Report - Version 08-18-2005 Page  PAGE 1 of  NUMPAGES 7 Copyright, 2005, Consortium for Children, All Rights Reserved PAGE  Structured Analysis Family Evaluation (SAFE) Nevada Couple Child Specific Home Study Report - Version 08-18-2005 Page  PAGE 8 of  NUMPAGES 2 Copyright, 2005, Consortium for Children, All Rights Reserved õĵŵƵ$h]ha$  !r'h]hh]h&`#$chiopqrvwõĵŵƵ㳯zz㳯vh5E!h*B0JCJOJQJmHnHuh*BCJOJQJh*BCJOJQJ h*B0Jjh*B0JUh*Bh*BCJOJQJ^JaJ!hV0JCJOJQJmHnHu!h X40JCJOJQJmHnHuh*B0JCJOJQJjh*B0JCJOJQJU%01h/R / =!"#$% 6 001h/R / =!"#$% 3 01h/R / =!"#$% 6 001h/R / =!"#$% 3 01h/R / =!"#$% 6 001h/R / =!"#$% 3 01h/R / =!"#$% : 00&P1h/R / =!"#$% D<Name of Public/Private Agencyu$$If!vh58(#v8(:V l t0658(jDPz$$If!vh58(#v8(:V l t0658(jDPz$$If!vh58(#v8(:V l t0658(jD-jDtD00000rD0000$$If!vh5h5 5 #vh#v #v :V l t065h5 5 jDPjDP$$If!vh5h5#vh#v:V l t065h50Df Select Onea resource familya legal risk familyadoptive parentsshelter parentsfoster parentsD<Name(s) of Child(ren) FIRST CAPITALjD$$If!vh5:5 #v:#v :V l4,5:5 / 4f4TjD$$If!vh5:5 #v:#v :V l4,5:5 / 4f4TjD$$If!vh5:5 #v:#v :V l4,5:5 / 4f4TjD$$If!vh5:5 #v:#v :V l4,5:5 / 4f4TD(Applicant's Full NameD(Applicant's Full Name$$If!vh55Y#v#vY:V l40w',55Y4af4TjDjD$$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjD jD $$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TD FIRST CAPITALjD $$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjD jD $$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjD jD $$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjD jD $$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjD jD $$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjDjD$$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjDjD$$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjDjD$$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjD jD $$If!vh55 5:5 #v#v #v:#v :V l40w',55 5:5 4af4TjDjD$$If!vh5 515C5#v #v1#vC#v:V l40w',5 515C54af4TDf Select OneNegativePositive InconclusiveExplained laterDf Select OneNegativePositive InconclusiveExplained later$$If!vh55 5~5 #v#v #v~#v :V l40w',55 5~5 4af4TjDDfOn FilePendingOther$$If!vh5Z5x#vZ#vx:V l0,5Z5x/ aTjD $$If!vh5Z5x#vZ#vx:V l0,5Z5x/ aTjDjD)jD/$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5jDjD)jD)$$If!vh5X5,5#vX#v,#v:V l t065X5,5$DProvide the Name(s), DOB, gender, reason for protective custody and legal status of the child(ren) or youth(s) being considered, e.g., reunification, reunification terminated, TPR hearing pending, freed for adoption, etc.fDIf the child(ren) or youth(s) is/are currently placed in the home, discuss their adjustment since placement. If not currently placed with the applicants, discuss the nature and character of the applicants' relationship(s) with the child(ren) or youth(s).hDDescribe the strengths, personality, interests and emotional/physical development of each child or youth being considered. Discuss the level of understanding each child/youth has about such issues as reunification,maintaining connections, adoption, etc. hDIdentify and take into account the special considerations noted on the SAFE Matching inventory, e.g. placement with siblings, special diet, accommodations for a physical disability, maintain connections with birth family, needs a stay-at-home parent, etc.DDDescribe the challenging child/youth issues identified on the SAFE Matching Inventory, e.g., difficult temperament, problematic behaviors, attachment issues,etc. Indicate whether or not therapeutic services are being used or are needed.$DProvide the Applicants' stated reasons for wanting the child(ren) placed with them and the parenting responsibilities they are willing to assume, e.g., foster parent, legal/risk parent, apdoptive parent or shelter parent.DHouse, Apt, Condo, Etc.s$$Ifl!vh5 5Z #v #vZ :V l65 5Z / 4aljDs$$Ifl!vh5 5Z #v #vZ :V l65 5Z / 4aljDs$$Ifl!vh5 5Z #v #vZ :V l65 5Z / 4aljDs$$Ifl!vh5 5Z #v #vZ :V l65 5Z / 4aljDs$$Ifl!vh5 5Z #v #vZ :V l65 5Z / 4al8DDescribe general characteristics of the Applicants' home and neighborhood. Indicate the type of residence (house, apartment, condo, etc.) and square footage. Describe the floor plan including the number of bedrooms and bathrooms.DDescribe the yard space and indicate if there is a pool or spa. Describe the sleeping arrangements and also indicate whether or not there are guns or pets in the home. jDDApplicant's full nameDDescribe how the applicant presents him/her self. Also indicate any special interests, hobbies, expertise or talents the applicant possesses.*D`Identify parents, siblings, their location and circumstances plus type and frequency of contact.dDIndicate name(s) and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated, e.g., death, divorce, annulment, breakup. Identify any children born of these unions and describe their current situation.DApplicant's full nameDDescribe how the applicant presents him/her self. Also indicate any special interests, hobbies, expertise or talents the applicant possesses.*D`Identify parents, siblings, their location and circumstances plus type and frequency of contact.dDIndicate name(s) and length of time of previous marriages and/or domestic partnerships. Include how relationships were terminated, e.g., death, divorce, annulment, breakup. Identify any children born of these unions and describe their current situation.DIndicate "None" or provide name(s), DOB and gender. Describe their personality, interests, school or occupational situation, general health and living situation. <DIndicate "None" or provide name(s), DOB, gender. Provide description of their personality, interests, school report information if any, general health. Indicate the nature of their relationship to the Applicants and living situation.DIndicate name of any adult who is living in the home or who is in the home on a regular basis. Describe the amount and type of contact they would have with a child or youth being considered.DIndicate each individual's occupation, general health, TB results (if they live in the home) and the nature of their relationship to the Applicants.4DeDescribe current and proposed child care arrangements and work and non-work day routines and rituals.DWhat are the basic household rules and expectations? Who does what in terms of chores, cooking, bill paying, home maintenance, transportation, etc.? Describe how the family deals with privacy and nudity in the home.DWhat kind of recreational, social and religious activities does the family engage in? Does the family celebrate holidays; which ones and how are they spent?BDlIndicate "None" or discuss the circumstances and the adjustment of the child(ren) or youth(s) to the family.jD DExplain, if anyD@Indicate the name(s) of any other individuals who were screened.D CHR FindingsD CANS FindingsDYIndicate FBI findings; DMV findings; local law enforcement check, or CPS service records.DIn case of an incapacitating illness or death of the Applicants, indicate whom the designated caretaker(s) will be and the nature of their relationship to the Applicants.DIndicate if these arrangements have been discussed with the designated caretaker(s), how willing they are to assume this responsibility and whether arrangements have been formalized in a will or trust.ZDDescribe the type of relationship and contact the Applicants are willing to have with the birth parents and other significant connections such as siblings, grandparents, foster parents, etc. Describe any written post-adoption contact agreement(s).DOIndicate if all references have been received. Summarize information provided.DIdentify and describe agency family preparation activities. Include Applicants' statements regarding their participation and benefits derived from these activities.DApplicant's full nameDApplicant's full namejDjDD<"Name(s) of Child(ren) or /Youth(s)Df Select Onewerewere not$$If!vh5'#v':V l t0,5'4i$$If!vh555555Z#v#v#v#vZ:V l  t<0,5555Z4p<kdz$$Ifl ֈ}fF/r'Z  t<04 lap<Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z/ 4Df21345Df21345$$If!vh55555Z#v#v#v#vZ:V l4 t0,5555Z/ 4f4Df21345Df21345w$$If!vh555555Z#v#v#v#vZ:V l  t<0,5555Z/ 4p<kd$$Ifl ֈ}fF/r'Z  t<04 lap<Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z/ / 4Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z/ 4Df21345N/ADf21345N/ADf21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345N/ADf21345N/ADf21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z/ 4Df21345$$If!vh55555Z#v#v#v#vZ:V l4 t0,5555Z4f4Df21345N/A5$$If!vh555555Z#v#v#v#vZ:V l  t0,5555Z/ 4pDf21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z/ 4Df21345Df21345$$If!vh55555Z#v#v#v#vZ:V l4 t0,5555Z/ 4f4Df21345Df21345w$$If!vh555555Z#v#v#v#vZ:V l  t<0,5555Z/ 4p<kd$$Ifl ֈ}fF/r'Z  t<04 lap<Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z/ 4Df21345Df21345Df21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z/ 4$$If!vh5555Z#v#v#v#vZ:V l4 t0,5555Z/ / 4f4n$$If!vh55555Z#v#v#v#vZ:V l4  t20+,5555Z/ / 4f4p2Df21345Df213450$$If!vh55555Z#v#v#v#vZ:V l4  t0+,5Z555Z/ / 4f4pDf21345Df21345Df Dropdown121345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df Dropdown121345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df Dropdown121345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df Dropdown121345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df Dropdown121345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df Dropdown121345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345Df21345Df Dropdown121345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z/ 4Df21345Df21345Df Dropdown121345$$If!vh555555Z#v#v#v#vZ:V l4 t0,5555Z/ / 4f4Df21345Df21345$$If!vh55555Z#v#v#v#vZ:V l4 t0,5555Z/ 4f46$$If!vh5555Z#v#v#v#vZ:V l4  t0+,5555Z/ / / 4f4pr$$If!vh55555Z#v#v#v#vZ:V l4  t20+,5Z555Z/ / 4f4p2Df21345N/ADf21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345N/ADf21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4Df21345N/ADf21345Df21345$$If!vh555555Z#v#v#v#vZ:V l4 t0,5555Z4f4Df21345N/ADf21345Df21345$$If!vh555555Z#v#v#v#vZ:V l4 t0,5555Z4f4Df21345N/ADf21345Df21345$$If!vh555555Z#v#v#v#vZ:V l t0,5555Z4XDDescribe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and degree of resolution.`DDescribe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change.`DDescribe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change.|DFor each person identified in this section, provide full narration that relates to each of the Desk Guide examples for the rating given. `DDescribe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change.`DDescribe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change.`DDescribe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change.`DDescribe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change.`DDescribe the basis for ratings of 1 (exceptional strengths). Briefly summarize ratings of 2 (strengths). Fully narrate ratings of 3, 4 & 5 (concerns) to include how the concern was addressed, severity, mitigating factors and the prognosis for change.fDBased on your Psychosocial Evaluation determinations, draw your conclusions about the Applicants' commitment, ability and readiness to parent. Cleary explain how a section with an Overall Evaluation of Section rating of 3, 4, or 5 will affect parenting.DFor families who participated in PRIDE Practice training, speak to the family's ability to meet the five PRIDE competencies below based on your psychosocial evaluation conclusions.D"Protecting and nurturing children:DKMeeting children's developmental needs and addressing developmental delays:D=Supporting relationships between children and their families: DQConnecting children to safe, nurturing relationships intended to last a lifetime:D+Working as a member of a professional team:DDiscuss each child's or youth's goodness of fit with this family in the context of the applicants' competency to address each of the child/youth's specific needs and special considerations.DIlluminate any special needs, considerations, characteristics, behaviors, conditions or issues of the child(ren) or youth(s) that the Applicants are uniquely qualified to address or unable to manage.DApplicant's full nameDApplicant's full nameDf Select OneapproveddeniedDf Select Oneadoptionfoster care placement"foster care placement and adoptionrelative placementrelative placement and adoption shelter careDName(s) of Child(ren)$$If!vh55@5555,#v#v@#v#v#v#v,:V l,55@5555,/ / 4~D- Caseworker~D- Supervisora$$If!vh5%5#v%#v:V l5%54tDTitletD#Titlea$$If!vh5%5#v%#v:V l5%54jDjD$$If!vh555 555 #v#v#v #v#v#v :V l,555 555 / / 4Df Select OneYesNoDf Select OneASFA (12 Elements)Square FootageN/ADf Select OneYesNoDf Select oneYesNoD/Indicate "None" or list additional attachments.M$$If!vh5'#v':V l,5'4$$If!vh55@5555,#v#v@#v#v#v#v,:V l,55@5555,/ / 4DApplicant's Full NameDApplicant's Full Nameg$$If!vh5%5#v%#v:V lF,5%54W$$If!vh5'#v':V l4,5'4f4jDjD$$If!vh555 555 #v#v#v #v#v#v :V l,555 555 / / 4@@@ NormalCJ_HaJmH sH tH D@D Heading 2$@&5CJOJQJH@H Heading 3$@&5CJOJQJaJT@T Heading 4$v&@#$/@&5OJQJ\F@F Heading 5$$@&a$ 5OJQJH@H Heading 6$@&5CJOJQJaJF@F Heading 8$@&5>*OJQJaJD @D Heading 9 $@&5OJQJaJDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List <>@< Title$a$5CJOJQJ>B@> Body TextCJOJQJaJ@ @@ Footer  ! 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