FCA Caregiver Interview

Caregiver Interview

Please complete to the best of your knowledge. You may skip any item that does not apply to the child and write "DK" if you don't know.
Today's Date *

Month Day Year
Date
Child's Name *

First Name Last Name
Child's DOB *

Month Day Year
Date
Child's Age *
Child's Ethnicity

Social/Family History
When was the child placed in your home? When and why was the child placed in CPS Custody? (please include what you know about the child’s exposure to neglect, abuse, and/or other trauma. Include previous RTC or psychiatric hospitalization)
(If you have already completed this section for a sibling seen on the same date, write “See Sibling History”)
Describe the current living situation (number of children in home, please specify whether biological, adopted, or foster children, other adults living in home):

Is the child currently receiving psychotherapy/counseling?

Yes No
If Yes, please specify the name of the therapist, frequency, and response to treatment.
Is the child currently having visits or other contact with biological parents or other family members?

Yes No
If Yes, please describe the nature of the visits and the child's response.
Are there any current plans for reuniting the child with the family, placement in adoption readiness, long-term placement in your home, placement in Residential Treatment or Psychiatric Hospital, etc.?

Yes No
If Yes, please describe.

Health History
Does the child have any handicapping conditions (not previously described)?

Yes No
If Yes, please describe.
Any known surgeries, injuries, chronic illnesses, medications or other physical problems?

Yes No
If Yes, please describe.
Are there any other concerns you would like to discuss?

Is the child currently taking pscyohactive medications (i.e. medication for mental health purposes)?

Yes No
If yes, do you consider the medications to be effective, overall?

Yes No
If not, please explain:
Please list current medications being taken.
Medication Strength   Mgs   How many per dose   NumberTime of day taken

Medication Strength Mgs   How many per dose Number
Time of day taken

Medication Strength Mgs How many per dose Number
Time of day taken
Medication Strength   Mgs   How many per dose   NumberTime of day taken

Medication Strength Mgs   How many per dose Number
Time of day taken

Medication Strength Mgs How many per dose Number
Time of day taken
Should be Empty: