Family Assessment
Submission Date
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Month
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Day
Year
Date
Your full name
Your date of birth
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Submitting Party
Mother
Father
Grandparent
Other
Full name / date of birth / gender of all children involved with child protective services.
For all children listed, give the name, date of birth or age, and address of the other parent.
Other persons in your household or a parent / children / adults. Full name / date of birth or age / gender / relationship
To the extent you or any other person in your household or a parent has a criminal history please describe.
To the extent any person in the household or a parent has mental health issues, please explain.
To the extent any person in the household or a parent has drug / alcohol / substance abuse issues, please explain.
Case No.
Judge
Magistrate
Have children been removed from their household or family?
Yes, they are in foster care.
Yes, they are in a facility.
Yes, but they are with family.
No
Other
Date of removal of children
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Month
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Day
Year
Date
Status - check all that apply
Investigation only
Removal of children - no court date
Court pending - no final order
Final order - on dependency
Termination of parental rights pending
Appeal
Other
Date of Filing / dependency or TPR
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Month
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Day
Year
Date
Date of Final Order
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Month
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Day
Year
Date
Describe your current living environment: (Housing type: apartment, house, etc.; Size of the home and number of bedrooms; Neighborhood; Distance to school/other parent)
Describe your current situation regarding work, income, others in the household working or contributing, and other benefits, on which you depend to financially support your family.
Permanency Planning
What are your strengths as a parent?
Describe any changes expected in your or the other parent's housing/work situation
Describe your parenting role: (doctor visits, church attendance, discipline, etc.
Concerns regarding your child(ren): (Physical health, behavioral or mental health issues, developmental concerns, etc:
Describe your relationship with the child(ren)
Concerns regarding your child(ren)'s education: (Grades, attendance, homework, peers, etc Grades, attendance, homework, peers, etc.)
Extracurricular activities of the children
Describe the other parent's parenting role
What are the strengths of the other parent?
Describe the other parent's relationship with the child(ren)
What are your concerns about the other parent? (Safety issues, discipline issues, drugs, alcohols, mental health, criminal record, etc
Do you and the other parent agree to a parenting arrangement? If so, what is it? If not, what are you seeking?
How have major parenting decisions been made in the past?
How are those major parenting decisions made now?
How do you want those major parenting decisions made in the future?
What are your goals for parenting and your involvement with the agency?
Describe your current parenting time or visiting schedule
Who might you call as witnesses should this case proceed to trial, what is vour relationship to them, and to what will they testify? (if known at this time)
Describe your support systems. (Family, community, friends, etc.)
What other family and friends will provide support or temporary placement?
Custody and Care issues
Health issues
Transportation/Exchanges
Healthcare
Education
Religion
Discipline/Routines
Counseling
Communication
Substance abuse
Conflict resolution
Other lifestyle issues
Physical or emotional violence
Financial distress
Day to day functioning
Budgeting
Other disabilities
Household or environmental inadequacy
Other - not listed
Signature
Typed Name
Date
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Month
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Day
Year
Date
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