ࡱ>      @ _bjbj "*`E4&&&h?L,0tA<$xR 5aaaa:a[0 Ɋ& X0L(n n 0n 0(}"}}}dB*qBFAMILY ASSESSMENT OF NEEDSHousehold Name: FORMTEXT      AND STRENGTHSPrimary Caretaker: FORMTEXT      Michigan Department of Human ServicesSecondary Caretaker FORMTEXT      DHS FC Worker Name: FORMTEXT      DHS FC Worker Load #: FORMTEXT      Check One:POS Agency Name: FORMTEXT       FORMCHECKBOX Initial Service PlanPOS Agency Worker: FORMTEXT       FORMCHECKBOX Updated Service PlanDate Completed: FORMTEXT      CHILDREN INFORMATION:Child s Name:Child Case Number:  FORMTEXT       FORMTEXT       Rate the caretaker(s) on all items, except for Item S14. Select the score that applies to each caretaker under each category. For items where the foster care worker is unable to obtain information at the ISP, Record US for Unable to Score. If a parent refuses contact at the 1st USP, US may be used with prior supervisory approval.Primary CaretakerSecondary CaretakerMost SeriousS1.Emotional Stability Behaviora. Exceptional coping skills +2b. Appropriate responses 0c. Some problems -3d. Chronic depression, severely low esteem, emotional problems -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN   FORMTEXT      S2.Parenting Skillsa. Strong skills +2b. Adequate skills 0c. Improvement needed -3d. Destructive/abusive parenting -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S3.Substance Abusea. No evidence of problem 0b. Caretaker w/substance problem/current treatment issues -3c. Caretaker with serious problem -4d. Problems resulting in chronic dysfunction -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S4.Sexual Abusea. No evidence of problem 0b. Caretaker has failed to protect child(ren) from sexual abuse -4c. Caretaker has abused child(ren) sexually -5d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S5.Domestic Relationsa. Supportive Relationship +2b. Single caretaker not involved in domestic relationship 0c. Domestic discord, lack of cooperation -2d. Serious domestic discord/domestic violence -4e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S6.Social Support Systema. Strong support system +2b. Adequate support system 0c. Limited support system -2d. No support or destructive relationships -4e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S7.Communication/Interpersonal Skillsa. Appropriate skills 0b. Limited or ineffective skills -2c. Isolating/hostile/destructive -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S8.Housinga. Adequate housing 0b. Some housing problems, but correctable -2c. No housing, eviction notice -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S9.Intellectual Capacitya. Average or above functional intelligence 0b. Some impairment, difficulty in decision making skills -2c. Severe limitation -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S10.Literacya. Literate 0b. Marginally literate -2c. Illiterate -3d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S11.Resource Availability/Managementa. Strong money management skills +1b. Sufficient income to meet needs 0c. Income mismanagement -2d. Financial crisis -3e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S12.Employmenta. Employed +1b. No need 0c. Unemployed but looking -1d. Unemployed, not interested -2e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S13.Physical Health Issuesa. No problem 0b. Health problem or physical limitation that affects family -1c. Serious health problems or physical limitation -2d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      S14.Child CharacteristicsChild(ren)a. Age appropriate, no problems 0b. Minor physical, emotional, intelligence problems -1c. One child has severe/chronic problems that result in substantial dysfunction -2d. Children have severe/chronic problems that result in substantial dysfunction -3e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMTEXT      Based on this assessment, identify below the priority needs and strengths of the household below (indicate S code only). Address the priority items in the Treatment Plan and Service Agreement and any needs scored under Substance Abuse:Household Name: FORMTEXT      PRIMARY NEEDSS1 Emotional Stability BehaviorS8 Housing1. FORMDROPDOWN S2 Parenting SkillsS9 Intellectual CapacityS3 Substance AbuseS10 Literacy2. FORMDROPDOWN S4 Sexual AbuseS11 Resource Availability / MgmtS5 Domestic RelationsS12 Employment3. FORMDROPDOWN S6 Social Support SystemS13 Physical Health issuesS7 Comm. / Interpersonal SkillsS14 Child CharacteristicsPRIMARY STRENGTHSS1 Emotional Stability BehaviorS8 Housing1. FORMDROPDOWN S2 Parenting SkillsS9 Intellectual CapacityS3 Substance AbuseS10 Literacy2. FORMDROPDOWN S4 Sexual AbuseS11 Resource Availability / MgmtS5 Domestic RelationsS12 Employment3. FORMDROPDOWN S6 Social Support SystemS13 Physical Health issuesS7 Comm. / Interpersonal SkillsS14 Child Characteristics FORMTEXT       Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. AUTHORITY: P.A. 280 OF 1939 RESPONSE: Voluntary. PENALTY: None MICHIGAN FOSTER CARE STRUCTURED DECISION MAKING FAMILY ASSESSMENT & REASSESSMENT OF NEEDS AND STRENGTHS DEFINITIONS S1. EMOTIONAL STABILITY A. Exceptional Coping Skills - Caretaker displays the ability to deal with adversity, crises, and long-term problems in a positive manner. Has a positive, hopeful attitude. B. Appropriate responses  Caretaker displays appropriate emotional responses. No apparent dysfunction. C. Some problems  Based on available evidence, caretaker's emotional stability appears problematic in that it interferes to a moderate degree with family functioning, parenting, or employment or other aspects of daily living. Indicators of "some" problems with emotional stability include: staff has repeatedly observed or been given reliable reports of indicators of low self-esteem, apathy, withdrawal from social contact, flat affect, somatic complaints, changes in sleeping or eating patterns, difficulty in concentrating or making decisions, low frustration tolerance or hostile behavior; frequent conflicts with coworkers or friends; few meaningful interpersonal relationships; speech is sometimes illogical or irrelevant; frequent loss of work days due to unsubstantiated somatic complaints; caretaker has been recommended for, or involved in, outpatient therapy within past two years; diagnosis of a mild to moderate disorder; or difficulty in coping with crisis situations such as loss of a job, divorce, or separation or an unwanted pregnancy. D. Chronic or severe problems - Caretaker displays chronic depression, apathy, and/or severe loss of selfesteem. Caretaker is hospitalized for emotional problems and/or is dependent upon medication for behavior control. observed, reported, or diagnosed chronic depression, paranoia, excessive mood swings; inability to keep a job or friends; suicide ideation or attempts; recurrent violence; stays in bed all day, completely neglects personal hygiene; grossly impaired communication (e.g., incoherent); obsessive/compulsive rituals; reports hearing voices or seeing things; diagnosed with severe disorder; repeated referrals for mental health/psychological examinations; recommended or actual hospitalization for emotional problems within past two years; severe impulsive behavior; or incapacitated by crisis situations. S2. PARENTING SKILLS A. Strong Skills - Caretaker displays knowledge and understanding of parenting skills and is utilizing these skills with child(ren) on a daily basis. Parent shows an ability to identify positive traits in their children (recognize abilities, intelligence, social skills, etc.), encourages cooperation and a positive identification within the family. B. Adequate skills  Caretaker displays adequate parenting patterns which are age-appropriate for the child in the areas of expectations, discipline, communication, protection, and nurturing. Caretaker has the basic knowledge and skills to parent. C. Improvement needed  Improvement of basic parenting skills needed by caretaker. Caretaker has some unrealistic expectations, gaps in parenting skills, demonstrates poor knowledge of age-appropriate disciplinary methods, is ambivalent about parenting, and/or lacks knowledge of child development which interferes with effective parenting. Includes: frequent parent/child conflict over discipline; children sometimes left unsupervised; parents sometimes inattentive to child's emotional needs or are rejecting; any single preponderance of evidence referral for inappropriate discipline, violent behavior towards child(ren), lack of supervision, or failure to thrive (includes current); parent lacks knowledge/needs assistance in dealing with special needs child(ren); or occasional parent/child role reversal. D. Destructive/abusive parenting  Caretaker displays destructive/abusive parenting patterns. Based on available evidence, it appears that caretaker(s) uses extreme punishment, or that their actions are tantamount to emotional abuse/neglect or that caretaker has abdicated responsibility for supervision, protection, discipline and/or nurturance. Indicators include: two or more preponderance of evidence referrals for inappropriate discipline, violent behavior towards child(ren), lack of supervision, or failure to thrive (prior and current); caretaker makes it clear that child(ren) are not wanted in home; discipline routinely involves use of an instrument (belt, board) or unusual deprivation (lock in cellar or closet); routine badgering and belittling of child(ren); caretaker discipline and control completely ineffective or caretaker makes no effort; caretaker unable to prevent abuse by others; caretaker contributes to child's delinquent involvement; prior termination of parental rights for sibling(s); persistent parent-child role reversal; caretaker refuses/unwilling to acknowledge that child has been sexually abused. S3. SUBSTANCE ABUSE A. No evidence of problems  No evidence of a substance abuse problem with caretaker. Based on available evidence, it does not appear that the use of substances interferes with the caretaker's or the family's functioning. Use does not affect caretaker's employment, criminal involvement, marital or family relationships, or his/her ability to provide supervision, care, and nurturance for children. B. Caretaker with problem or current treatment issues  Caretaker displays substance abuse problem resulting in disruptive behavior or causing discord in family. Based on available evidence, it appears that caretakers substance abuse creates problems for the caretaker or the family. Consider as problems the following: the caretaker has been arrested once in the past two years for alcohol or drug-related offenses or has refused breathalyzer (PBT) testing; caretaker has experienced work-related problems in the past year as a result of substance use; staff have observed or received reliable reports that children have, on more than one occasion, been left unsupervised, inadequately supervised or let longer than planned by the caretaker because of substance abuse (i.e., caretaker physically absent due to use or passed out or seeking drugs); staff have observed or received reliable reports that caretakers substance abuse results in conflict in family over use (e.g., arguments between spouses or between children and caretaker over use); staff have observed withdrawal symptoms: twitching and tweaking (uneasiness), restlessness, runny nose, flu-like complaints, overly tired, multiple bathroom breaks in a short period of time, mood swings; house is in disarray, Activities of Daily Living not tended to; caretaker admits that he/she is experiencing some problems due to substance abuse; caretaker is currently in out-patient treatment (including AA/NA); caretaker has received treatment for substance abuse and has been in recovery for less than one year. OR, caretaker is currently receiving treatment or is attending a support program for substance abuse. C. Caretaker with serious problem  Caretaker has serious substance abuse problem resulting in such things as loss of job, problems with the law, family dysfunction. Based on available evidence, it appears that caretakers substance abuse creates serious problems for the caretaker or the family. Consider the following criteria as indicators of a serious problem: child born positive for drug exposure or Fetal Alcohol Disorder; caretaker has ever been fired for substance abuse (and has not sought or benefited from treatment); home raided; caretaker has been arrested two or more times for alcohol or drug-related offenses within the last year; staff have observed indicators of intoxication such as slurred speech, glassy eyes, unsteady gait, order of alcohol, drug paraphernalia; unusual strong order in home similar to cat urine, nail polish remover, ammonia or ether; large amounts of products such as cold medicines, antifreeze, drain cleaners, lantern fuel, duct tape, coffee filters, batteries or clear glass beakers and containers; reliable reports of, or staff have observed, violence toward family members by caretaker while under the influence; reliable reports of daily intoxication; caretaker has been diagnosed as substance dependent and has received treatment within past two years and is still using; child or spouse reports observation of caretaker using drugs, or children have knowledge of whereabouts of drugs in household; history of positive and/or missed urine screens and PBTs. D. Problems resulting in chronic dysfunction  Caretaker has chronic substance abuse problems resulting in a chaotic and dysfunctional household/lifestyle. There has been a pattern of serious, long-term problems related to substance abuse. Other examples may include but are not limited to: multiple job losses; multiple arrests that are related to the caretakers substance abuse; caretaker has had a serious problem with substance abuse, has been in treatment multiple times, and has had multiple relapses; caretaker has a serious medical problem(s) resulting from substance abuse: Hepatitis B, C or D, HIV, cirrhosis, esophageal problems, irritable bowel, acute pancreatitis, repeated Sexually Transmitted Diseases; toxic psychosis; extreme weight loss; there has been regular pre-natal exposure of children to substances - this includes exposure in more than one pregnancy, children diagnosed Fetal Alcohol Spectrum Disorder, or children medically determined substance dependent at birth. S4. SEXUAL ABUSE A. No evidence of problem  Caretaker is not known to be a perpetrator of child sexual abuse. B. Failed to protect  Caretaker has failed to protect a child from sexual abuse. C. Evidence of sexual abuse  Caretaker is known to be a perpetrator of child sexual abuse. S5. DOMESTIC RELATIONS A. Supportive relationship  Supportive relationship exists between caretakers and/or adult partners. Caretakers share decision making and responsibilities. B. Single caretaker not involved in domestic relationship  Single caretaker. C. Domestic discord, lack of cooperation  Current marital or domestic discord. Lack of cooperation between partners, open disagreement on how to handle child problems/discipline. Frequent and/or multiple partners. D. Serious domestic discord/domestic violence  Serious marital discord or domestic violence. Repeated history of leaving and returning to abusive spouse or partners. Involvement of law enforcement in domestic violence problems, restraining orders, criminal complaints. S6. SOCIAL SUPPORT SYSTEM A. Strong support system - Caretaker has a strong, constructive support system. Active extended family (may be blood relations or close friends) who provide material resources, child care, supervision, role modeling for parent and children, and/or parenting and emotional support. B. Adequate support system  Caretaker uses extended family, friends, community resources to provide a support system for guidance, access to child care, and available transportation, etc. C. Limited support system  Caretaker has limited support system, is isolated, or reluctant to use available support or support system is negative. D. No support or destructive relationships  Caretaker has no support system and/or caretaker has destructive relationships with extended family and community resources. S7. COMMUNICATION/INTERPERSONAL SKILLS A. Appropriate skills  Caretaker appears to be able to clearly communicate needs of self and children and to maintain both social and familial relationships. B. Limited or ineffective skills  Caretaker appears to have limited or ineffective interpersonal skills within the family and community which limit ability to make friends, keep a job, communicate needs of self or children to schools or agencies. C. Isolated/hostile/destructive  Caretaker isolates self/children from outside influences or contact, and/or have interpersonal skills that are hostile/destructive towards family members or others. Available evidence indicates very chaotic, disrespectful communication or behavior patterns or extreme isolation; very diffuse or extremely rigid personal boundaries; extreme emotional separateness or attachment. S8. HOUSING A. Adequate housing  Family has adequate housing of sufficient size to meet their basic needs. B. 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Available evidence indicates that caretaker's intellectual ability impairs their ability to function independently and to care for child(ren). Indicators include: deficiencies, even after instruction, in everyday living skills such as taking a bus, shopping for food or clothing, or using money; difficulties in performing, even after instruction, such basic child care tasks as preparing formula, changing diapers, taking temperatures, administering medication, preparing meals, or dressing children appropriately for weather conditions; grossly inappropriate social behavior for chronological age; previous school placement in a special education or developmental disabilities program; caretakers' IQ indicates that he/she is mentally impaired (score of 50-55 to approximately 70). S10. LITERACY A. Literate - Caretaker has functional literacy skills, is able to read and write adequately to obtain employment, and assist children with school work. B. Marginally literate  Caretaker has marginally functional literacy skills that limit employment possibilities and ability to assist children. C. Illiterate  Caretaker is functionally illiterate and/or totally dependent upon verbal communication. D. Severe limitation  Caretaker is limited intellectually and/or cognitively to the point of being marginally able or unable to make decisions and care for self, or to think abstractly. It appears that the caretaker has severely limited intellectual ability and that it seriously limits or prohibits ability to function independently and to care for child(ren). Indicators of a major problem include: caretakers IQ indicates that he/she is moderately, severely, or profoundly mentally impaired (score below 50-55); caretaker's employment is in a sheltered workshop or is unable to work; outside assistance is provided or has been recommended for caretaker's daily living; previously placed in, or recommended for, residential treatment facility, or specialized group home because of limited intellectual ability; inability to recognize and respond appropriately to situations requiring prompt medical attention (e.g., diarrhea, fever, vomiting) or emergency medical care (e.g., potential broken bones, serious burns) for family members; restricted ability to make judgments to protect the child(ren) from abuse, neglect, or injury. S11. RESOURCE AVAILABILITY/MANAGEMENT A. Strong money management skills  Family has limited means and resources but family's minimum needs are consistently met. B. Sufficient income  Family has sufficient income to meet basic needs and manages it adequately. C. Income mismanagement  Family has sufficient income, but does not manage it to provide food, shelter, utilities, clothing, or other basic or medical needs, etc. D. Financial crisis  Family is in serious financial crisis and/or has little or no income to meet basic family needs. S12. EMPLOYMENT A. Employed - One or both caretakers are gainfully employed. B. No need - One or both caretakers are gainfully employed, or are out of labor force, e.g., fulltime student, disabled person, or homemaker. C. Unemployed, but looking  One or both caretakers need employment or are under-employed and engaged in realistic job seeking or job preparation activities. D. Unemployed, but not interested  One or both caretakers need employment, have no recent connection with the labor market, are not engaged in any job preparation activities nor seeking employment. S13. PHYSICAL HEALTH ISSUES A. No problem  Caretaker does not have health problems that negatively affect family functioning. B. Health problem, physical limitation that negatively affects family - Caretaker has a health problem or physical limitation that negatively affects family functioning. This includes pregnancy of the caretaker. C. Serious health problem, physical limitation  Caretaker has a serious/chronic health problem or physical limitation that affects ability to provide for and/or protect children. S14. CHILD CHARACTERISTICS A. Age appropriate  Child(ren) appears to be age-appropriate, with no abnormal or unusual characteristics. B. Minor problems  Child(ren) has minor physical, emotional, or intellectual difficulties. Minor child is pregnant. C. Significant problems - One child has significant physical, emotional, or intellectual problems resulting in substantial dysfunction in school, home, or community which puts strain on family finances and/or relationships. D. Severe problems  More than one child has significant physical, emotional, or intellectual problems resulting in substantial dysfunction in school, home, or community which puts strain on family finances and/or relationships. DHS-145 (Rev. 2-06) Previous edition obsolete. MSWord  PAGE 10 iطso%T[gq TUpTh456EOPVWYZĭ)h(R0JCJOJQJ^JaJmHnHu$hZYhP*0JCJOJQJ^JaJ-jhZYhP*0JCJOJQJU^JaJhP*CJOJQJ h =hEdh =h~<B* phh =h!<>*B* phh =h!<B* phU3շopklt~ݽ޽P8 & F8 80^`0PQGHdQRmPQ12\]  !d|)$ P+d?]a$8 80^`0Z[]^_$&(*>@BLNTVh*tj UCJjUmHnHuj U jU h =hEdh(RhP*hP*0JCJOJQJ]^_(PRTVOkd $$Ifl40!+,"W +4 laf4$If$If$ P+d?]a$200&PPBP/ =!"#$%=; 000&PP:p>TBP/ =!"#$%=; 000&PP:p>TBP/ =!"#$%=D HouseholdName*Enter in assigned Foster Care case number. CaseInfo.MAIN$$If!vh555#v#v#v:V l+,555/ / / / /  / 4DPrimaryCaretaker(Enter in assigned Foster Care case name.$$If!vh555#v#v#v:V l+,,555/  / / /  / 4DSecondaryCaretaker$Enter assigned worker's load number.$$If!vh555#v#v#v:V l+,,555/ / / / /  / 4D FCWorkerName,Enter assigned worker's first and last name.$$If!vh555#v#v#v:V l+,555/ / / / /  / 4DPSCaseNoEnter PS case number.$$If!vh555#v#v#v:V l+,555/ / / / /  / 4DPOSAEnter PS Case Number$$If!vh555#v#v#v:V l+,555/ / / / /  / 4DeInitAssessmentCheck if appropriate. DPOSW*Enter Court ID number assigned to FC case.$$If!vh555\ 55#v#v#v\ #v#v:V l+,555\ 55/  / / 4De ReassessmentCheck if appropriate.$$If!vh555\ 55#v#v#v\ #v#v:V l4+555\ 55/ 4f4w$$If!vh555#v#v#v:V l+5554D DateCompleted=Enter the Date (Example: 4/12/1997) assessment was completed.$$If!vh55\55 5 #v#v\#v#v #v :V l+55\55 5 / 4g$$If!vh5 5 #v #v :V l4+5 5 4f4g$$If!vh5,"5W #v,"#vW :V l4+5,"5W 4f4D ChildNameAddidentInfoAutotDText3m$$If!vh5,"5W #v,"#vW :V l4+,5,"5W 4f4m$$If!vh5,"5W #v,"#vW :V l4+,5,"5W 4f4]$$If!vh5\5'#v\#v':V l+5\5'4$$If!vh55z 5555 5w5#v#vz #v#v#v#v #vw#v:V l+55z 5555 5w5/ 4G$$If!vh5+#v+:V l+5+4$$If!vh5 55552 5s #v #v#v#v#v2 #vs :V l4+5 55552 5s / 4f4$$If!v h5 55555555 #v #v#v#v#v#v#v#v :V l4+5 5555555 4f4$$If!vh5 555555T#v #v#v#v#v#vT:V l4+5 55555T4f4 $$If!vh5555555T#v#v#v#v#v#vT:V l4+555555T4f4pF $$If!vh5555555T#v#v#v#v#v#vT:V l4+555555T4f4pF $$If!vh5555555T#v#v#v#v#v#vT:V l4+555555T4f4pF $$If!vh5555555T#v#v#v#v#v#vT:V l4+555555T4f4pF^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +20-3-5USZDfbS1. Emotional Stability Behavior - select appropriate score for Secondary Caretaker in household 1 +20-3-5USZDfbS1. Emotional Stability Behavior - select appropriate score for Secondary Caretaker in household 1 +20-3-5US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kd$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4DText21Enter narrative for Emotional Stability Behavior.g$$If!vh55)#v#v):V l4+55)4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +20-3-5USZDfbS1. Emotional Stability Behavior - select appropriate score for Secondary Caretaker in household 1 +20-3-5USZDfbS1. Emotional Stability Behavior - select appropriate score for Secondary Caretaker in household 1 +20-3-5US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kd+$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D%Enter narrative for Parenting Skills.g$$If!vh55)#v#v):V l4+55)4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-3-4-5US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-3-4-5US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-3-4-5US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kd9$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D$Enter narrative for Substance Abuse.g$$If!vh55)#v#v):V l4+55)4f4c$$If!vh55)#v#v):V l4+55)4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4$$If!vh555555s #v#v#v#v#vs :V l4+55555s / 4f4XDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-4-5USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-4-5USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-4-5US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kdF$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D!Enter narrative for Sexual Abuse.g$$If!vh55)#v#v):V l4+55)4f4c$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +20-2-4US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +20-2-4US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +20-2-4US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kdS$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D'Enter narrative for Domestic Relations.g$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +20-2-4US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +20-2-4US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +20-2-4US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kda$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D*Enter narrative for Social Support System.g$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4XDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kdn$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D7Enter narrative for Communication/Interpersonal Skills.g$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4XDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kd{$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4DEnter narrative for Housing.g$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4XDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-4US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kdk$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D*Enter narrative for Intellectual Capacity.g$$If!vh55)#v#v):V l4+55)4f4c$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4XDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-3USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-3USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-2-3US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kd$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4DEnter narrative for Literacy.g$$If!vh55)#v#v):V l4+55)4f4c$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +10-2-3US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +10-2-3US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +10-2-3US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kd`$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D5Enter narrative for Resource Availability/Management.g$$If!vh55)#v#v):V l4+55)4f4c$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +10-1-2US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +10-1-2US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  +10-1-2US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kd$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4DEnter narrative for Employment.g$$If!vh55)#v#v):V l4+55)4f4c$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4XDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-1-2USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-1-2USXDfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-1-2US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kdo$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D+Enter narrative for Physical Health Issues.g$$If!vh55)#v#v):V l4+55)4f4c$$If!vh55)#v#v):V l4+55)4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4$$If!vh55552 5s #v#v#v#v2 #vs :V l4+55552 5s / 4f4^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-1-2-3US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-1-2-3US^DfdS1. Emotional Stability Behavior - select appropriate score for Primary Caretaker in household 1  0-1-2-3US$$If!v h5555-55 55 5 5 T#v#v#v#v-#v#v #v#v #v #v T:V l4+5555-55 55 5 5 T/ / / 4f4pd/kdF$$Ifl4 dr#$+-  T+((((4 laf4pdc$$If!vh55)#v#v):V l4+55)4f4D*Enter narrative for Child Characteristics.g$$If!vh55)#v#v):V l4+55)4f4M$$If!vh5+#v+:V l4+5+4f4G$$If!vh5+#v+:V l+5+4DText4Enter household name.$$If!vh5555$ 5 #v#v#v#v$ #v :V l4+,5555$ 5 / / 4f4 $$If!v h555v55v5555 s #v#v#vv#v#vv#v#v#v#v s :V l4+555v55v5555 s /  4f4\Df Dropdown19Select first of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14K$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / / 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4=$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / 4f4kdR$$Ifl4 $ drlz+  hvvs +,,,,4 laf4LDf:Select second of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14K$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / / 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4=$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / 4f4kd $$Ifl4 $ drlz+  hvvs +,,,,4 laf4JDf9Select third of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14K$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / / 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4=$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4=$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4 $$If!v h555v55v5555 s #v#v#vv#v#vv#v#v#v#v s :V l4+555v55v5555 s /  4f4$$If!vh5552 5s #v#v#v2 #vs :V l4+5552 5s / 4f4RDf=Select first of top three priority strengths for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14=$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4/$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s 4f4kdK$$Ifl4 $ drlz+  hvvs +,,,,4 laf4TDf>Select second of top three priority strengths for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14=$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s / 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4/$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4RDf=Select third of top three priority strengths for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14C$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,, 5 5 5h55v55v55 5 5 s / 4f4kdb$$Ifl4 $ drlz+  hvvs +,,,,4 laf4/$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4/$$If!v h5 5 5h55v55v55 5 5 s #v #v #vh#v#vv#v#vv#v#v #v #v s :V l4+,5 5 5h55v55v55 5 5 s 4f4kd$$Ifl4 $ drlz+  hvvs +,,,,4 laf4M$$If!vh5+#v+:V l4+5+4f4DText1+Enter Worker Name and Typist Initials, etc.M$$If!vh5+#v+:V l4+5+4f4c$$If!vh55)#v#v):V l4+55)4f4q$$If!vh55#v#v:V l4+55/ 4f4jDjDm$$If!vh5,"5W #v,"#vW :V l4+,5,"5W 4f4;8@8 Normal_HmH sH tH DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List <&@< Footnote Reference4@4 Header  !4 @4 Footer  !.)@!. 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