ࡱ> ]`TUVWXYZ[\z @ Oˊbjbj y$wm       tHlDR V^}}}}}}$RTA   &'''  '''Bw  9F  pW5QE>H8<DE6#!6|9F    6 GF'd1'1CHILDREN S FOSTER CARERESIDENTIAL UPDATED SERVICE PLAN (4 - 9 years)Michigan Department of Human Services  MACROBUTTON [sjc] "Click Here to Enter Agency Name and Address"  Date of Report: FORMTEXT      Report Period: FORMTEXT       Through  FORMTEXT      I.Identifying Information A. Child: Enter the child s name, date of birth, case number, the facility name, specific program name and address of the facility, date entered out of home placement, current placement type, date of current placement, and the next anticipated placement of the child and the anticipated placement date as specified by DHS. Indicate the permanency planning goal (as specified by DHS), sex, and race of the child. Name:Date of Birth:Case Number: FORMTEXT       FORMTEXT       FORMTEXT      Child s Address:Date Entered Care: FORMTEXT       FORMTEXT      Current Placement Type:Date of Current Placement:Anticipated Next Placement Type:Date Anticipated Next Placement: FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMTEXT      Perm. Plan Goal FORMDROPDOWN  Sex: Race:Check if Ethnicity is Hispanic/Latino: FORMDROPDOWN  FORMDROPDOWN  FORMCHECKBOX Parent (Caretaker) Name(s): For each adult parent or caretaker, non-parent adult with a significant relationship or who is a potential placement, provide the name and relationship to child, the address and telephone number, date of birth, sex and race of the person. Name:Relationship:Date of Birth: FORMTEXT       FORMTEXT       FORMTEXT      Parent s Current Address:Telephone: FORMTEXT       FORMTEXT      Sex:Race:Check if Ethnicity is Hispanic / Latino: FORMDROPDOWN  FORMDROPDOWN  FORMCHECKBOX Commitment or Referral Information:DHS Local Office Name:DHS Worker Name:DHS CDUL No s.:DHS Worker Telephone: FORMTEXT       FORMTEXT       FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT    FORMTEXT      POS Agency Name:POS Agency Worker Name:POS Agency Telephone: FORMTEXT       FORMTEXT       FORMTEXT      Court ID Number:Judge s Name:Judge s Telephone: FORMTEXT       FORMTEXT       FORMTEXT      II.Legal Status Add the information in this section as requested. Initial Wardship is TCW or MCI Ward as specified by the DHS worker. In the space following this section, add any pertinent narrative concerning court requirements.Initial Wardship Type and DateLast Court Type and Date FORMTEXT       FORMTEXT      Current Wardship Type and DateNext Court Type and Date FORMTEXT       FORMTEXT        MACROBUTTON [1] "Click Here and Type"   III.Social Work Contacts List date, person contacted, role/position, type of contact (telephone, in person, home visit, office visit, etc.) for each contact, attempted contact, and scheduled, but unkept, appointment. If desired, provide a brief narrative statement of the specific reason for the contact. Limit the narrative to one sentence.  MACROBUTTON [1] "Click Here and Type"   IV.Child AssessmentA.Child Status Describe for the child addressed in this report; emotional and physical development, past experiences and, problems since the most recent assessment. Include a physical description of the child, hobbies, likes and dislikes, etc and any changes since the most recent assessment and report. Describe the childs adjustment to residential placement and services. List all siblings Describe the services provided, offered to or planned for the child, parent(s), guardian, or custodian, and non-parent adult including potential placements, if applicable, to return the child home or move to less restrictive placement. Discuss planning for aftercare. List dates of individual/group counseling/therapy. List primary treatment goals. Describe progress achieved during this report period. Indicate the anticipated next placement and the projected time frame for the placement.  MACROBUTTON [1] "Click Here and Type"   B.Child Needs and Strengths AssessmentAddress and explain each individual item scored as strength or need on the Child Assessment of Needs and Strengths for the child in the space provided following each item. Provide the reasons that each item is scored as a strength or need. If there are significant discrepancies between facility scoring of any need item and the worker with primary family responsibility, it must be identified and resolved through a conference with the family worker.ItemC1.Medical/Physical Was there prenatal drug/alcohol exposure? Y N U/K FORMDROPDOWN a. Good Health +5b. Adequate health 0c. Situational concerns -2d. Impaired health -3e. Severely impaired health -5f. Unable to score US FORMDROPDOWN C1. MEDICAL/PHYSICAL HEALTH Was there prenatal drug/alcohol exposure? Answer yes, no, or unknown. A. Good health. Child has no known health care needs; child receives routine preventive and medical/dental/vision care, immunizations, health screenings, and hygiene care. If child resided in a high risk environment for lead exposure, the child has received a lead exposure screening. B. Adequate health. Child has no unmet health care needs or has minor health problems (ex. allergy shots/medications, etc.) that can be addressed with routine intervention; age-appropriate immunizations and annual medical exams and required health screenings are current. C. Situational concern. Child has a special condition(s)/health concern(s) (ex. lice, cold/flu, ear infections, bone fracture, etc.) that may require temporary (anticipated not to exceed 90 days) medical treatment (ex. follow-up with medical personnel, administering of prescription or over-the-counter medications, etc.); and/or child has not received required immunizations or health screenings (including lead exposure if child resided in a high risk environment for lead exposure). D. Impaired health. Child has a medical condition(s) that may impair daily functioning (ex. fragile asthmatic, eczema, allergies, etc.) and requires ongoing interventions. This may include effects of prenatal drug exposure and/or effects of lead exposure. E. Severely impaired health. Child has a serious, chronic, or acute health condition(s) (ex., diabetes, cerebral palsy, pronounced effects of lead exposure, etc.) that severely impairs functioning and requires ongoing intervention(s)..  MACROBUTTON [1] "Click Here and Type"  ItemC2.Mental Health and Well-Beinga. Healthy emotional behavior/coping skills +5b. Appropriate emotional behavior/coping skills 0c. Situational concern -2d. Limited emotional behavior/coping skills -3e. Severely limited emotional behavior/coping skills -5f. Unable to score US FORMDROPDOWN C2 MENTAL HEALTH AND WELL-BEING A. Healthy emotional behavior/coping skills. Child consistently exhibits an age-appropriate range of emotional behaviors; child displays strong age-appropriate coping skills in dealing with disappointment, anger, grief, stress, and daily challenges in home, school, and community; child is also able to identify the need for, seeks, and accepts guidance; child has a positive and hopeful attitude and readily adjusts to new situations. B. Appropriate emotional behavior/coping skills. Child generally exhibits an age-appropriate range of emotional behaviors. Child displays developmentally appropriate emotional coping responses that do not, or minimally interfere with, school, family, or community functioning. Child has age-appropriate ability to cope with a range of emotions and social environments. Child has ability to adjust to new situations. C. Situational concern. Child may demonstrate some symptoms reflecting situational sadness, anxiety, aggression, or withdrawal. Maintains situationally-appropriate emotional control. This does not include short-term, adverse reactions to parental visitation, but could include response to initial placement or re-placement (ex. temper tantrums, nightmares, loss of appetite, bedwetting, etc.). D. Limited emotional behavior/coping skills. Child has some difficulty dealing with daily stresses, crises, or problems which interfere with family, school, and/or community functioning. Problems may include, but are not limited to, withdrawal from social interaction, flat affect, changes in sleeping or eating patterns, increased aggression, unusually low frustration/tolerance, etc. E. Severely limited emotional behavior/coping skills. Child has consistent difficulty in dealing with daily stresses, crises, or problems which severely impair family, school, and/or community functioning. Child may have diagnosed psychiatric disturbance and may demonstrate severe behavior such as fire setting, suicidal behavior, violence toward people and/or animals, self mutilation, etc. Child frequently threatens to run away from placement.  MACROBUTTON [2] "Click Here and Type"  Item C3.Child Developmenta. Advance development +5b. Age-appropriate development 0c. Situational concern -2d. Limited development -3e. Severely limited development -5f. Unable to score US FORMDROPDOWN C3 CHILD DEVELOPMENT For this item, base assessment on developmental milestones as described in the Stages of Development Table of the Foster Care Manual (CFF 722-8B STAGES OF DEVELOPMENT TABLE). A. Advanced development. Childs development is above chronological age level. Child meets all physical, language/communication, and cognitive developmental milestones. B. Age-appropriate development. Childs development is consistent with chronological age level. Child meets most physical, language/communication, and cognitive developmental milestones. C. Situational concern. Child has a situational concern in physical, language/communication, and/or cognitive development as the result of an experience which causes an interruption in progress toward developmental milestone achievement. D. Limited development. Child has some delays in meeting physical, language/communication, and/or cognitive developmental milestones. Some services and intervention required. E. Severely limited development. Child has severe delays in meeting physical, language/communication, and/or cognitive developmental milestones. Formalized services and structured intervention required..  MACROBUTTON [2] "Click Here and Type"  ItemC4.Family and Kin/Fictive Kin Relationships/Attachmentsa. Nurturing/supportive relationships/attachments +5b. Appropriate relationships/attachments 0c. Situational concern -2d. Limited relationships/attachments -3e. Severely limited relationships/attachments -5f. Unable to score US FORMDROPDOWN C4 FAMILY AND KIN/FICTIVE KIN RELATIONSHIPS/ATTACHMENTS Score the childs interaction with his/her family (those individuals the child is related to or views as family). For children in placement, base assessment on visits and other contact such as telephone contact or letters. A. Nurturing/supportive relationships/attachments. Child has positive interactions with and exhibits strong attachments to family, kin, fictive kin, and/or caregiver. Child has sense of belonging with family. B. Appropriate relationships/attachments. Child has positive interactions with and exhibits appropriate attachments to family, kin, fictive kin, and/or caregiver despite some minor conflicts. C. Situational concern. Child experiences temporary strain in interaction with family members. Child may be temporarily angry with the family and/or lacks desire for family interaction (ex. visitation, telephone contact, threatens truancy if visit occurs, refuses to participate in family therapy, etc.). D. Limited relationships/attachments. Child does not have positive interactions with family, does not exhibit appropriate attachments to family, kin, fictive kin, and/or caregiver. Child does not have a sense of belonging with family. E. Severely limited or no relationships/attachments. Child has no interactions or has non-supportive, destructive interactions with family, and exhibits negative attachments to family, kin, fictive kin, and/or caregiver.  MACROBUTTON [2] "Click Here and Type"  ItemC5.EducationDoes child have a special education plan? Y N FORMDROPDOWN Does child need an assessment for special education/early intervention? Y N  FORMDROPDOWN a. Exceptional academic achievement +4b. Adequate achievement 0c. Situational concern -1d. Minor difficulty -2e. Major/chronic difficulty -4f. Unable to score US FORMDROPDOWN C5 EDUCATION Does the child have a special education plan? Answer yes or no. Does the child need assessment for special education/early intervention? Answer yes or no. A. Exceptional academic achievement. Child is working above grade level and/or is exceeding the expectations of the childs specific educational plan. If child is not of mandatory school age, and is not attending school, the childs cognitive functioning exceeds developmental milestones. B. Adequate achievement. Child is working at grade level and/or is meeting expectations of the childs specific educational plan. If the child is not of mandatory school age, and is not attending school, the child meets most cognitive developmental milestones; or if there are early intervention needs, the child is participating in early intervention services and is meeting or exceeding the goals/expectations of the early intervention plan. C. Situational concern. Child may demonstrate some school difficulties (ex., decreased concentration in the classroom, acting-out behavior, regression in academic performance, etc.) that appear temporary in nature. D. Minor difficulty. Child is working below grade level in at least one, but not more than half of subject areas, indicating that the current educational plan may need modification. The child may be exhibiting minor truancy or school behavioral problems. If the child is not of mandatory school age, and is not attending school, the child has minor cognitive developmental delays and/or is not meeting some of the goals of the early intervention plan. E. Major/chronic difficulty. Child is working below grade level in more than half of subject areas and/or is not meeting the goals of the existing educational plan, indicating that the current plan needs modification, or the child needs a specific educational plan and does not have one in place. Score this item for a child who is legally required to attend school and is not attending, or who has been expelled/excluded from school. If the child is not of mandatory school age, and is not attending school, the child has severe cognitive developmental delays and/or is not meeting any of the goals of the early intervention plan.  MACROBUTTON [2] "Click Here and Type"  ItemC6.Substance Use (Substances include alcohol, tobacco, and other drugs)a. No substance use +1b. Past experimentation 0c. Situational concern -1d. Current substance use -2e. Frequent substance use -4f. Unable to score US FORMDROPDOWN C6 SUBSTANCE USE (Substances include alcohol, tobacco, and other drugs) A. No substance use. Child does not use alcohol, drugs, or other substances and is age-appropriately aware of consequences of use. Child is not in peer relationships/social activities involving alcohol and/or other drugs and/or chooses not to use despite peer-pressured opportunities to use. No demonstrated history or current problems related to substance use. B. Past experience. Child may have past experience with alcohol and/or other drugs but there is no indication of sustained use. C. Situational concern. Child may have an isolated incident or experience with alcohol, tobacco, or other drugs that is not recurring. D. Current substance use. Childs alcohol and/or other drug use has resulted in problematic behavior at home, school, and/or in the community. Use may include multiple drugs. Child may be involved in peer relationships/social activities involving alcohol, drugs, and other substances. E. Frequent substance use. Childs frequent alcohol, drug, or other substance usage results in severe behavior disturbances at home, school, and/or in the community. Child may require medical intervention to detoxify.  MACROBUTTON [2] "Click Here and Type"  ItemC7.Sexual BehaviorHas child been sexually abused? Y N U/K FORMDROPDOWN Does child demonstrate sexually inappropriate behavior? Y N U/K FORMDROPDOWN a. Healthy sexual adjustment/responsible behavior +1b. Appropriate sexual adjustment/behavior 0c. Situational concern -1d. Compromised sexual adjustment/behavior -2e. Severely compromised sexual adjustment/reckless behavior -4f. Unable to score US FORMDROPDOWN C7 SEXUAL BEHAVIOR Has child been sexually abused? Answer yes, no, or unknown. Does child demonstrate sexually inappropriate behavior? Answer yes, no, or unknown. Examples may include, but are not limited to, a child who engages in persistent self-stimulation, chronically acts-out toward others children in sexually inappropriate ways, or engages in sexual contact with others. A. Healthy sexual adjustment/responsible behavior. Child displays no signs or history of sexual abuse or exploitation. Child exhibits developmentally appropriate sexual awareness and interest. B. Appropriate sexual adjustment/behavior. Child does not show any indications of their past sexual abuse and responds to treatment/intervention. Child may participate in age-appropriate sexual behavior or may show age-appropriate interest in sexuality. C. Situational concern. Child has begun to exhibit heightened interest/awareness of sexuality that may be a response to a change in situation or incident, such as inappropriate touching and/or comments/language. D. Compromised sexual adjustment/behavior. Child is displaying inappropriate behavior due to known or suspected sexual abuse or exploitation. Behaviors may include more sexualized behaviors than same aged children, preoccupation with sexual themes, increased masturbation, and/or simulating sex acts. E. Severely compromised sexual adjustment/behavior. Child exhibits extreme sexualized behaviors which may include frequent masturbation, persistent sexually acting out behaviors toward others, etc.  MACROBUTTON [2] "Click Here and Type"  ItemC8.Peer/Adult Social Relationships (Non-Family)a. Strong social relationships +3b. Adequate social relationships 0c. Situational concern -1d. Limited social relationships -2e. Severely limited social relationships -3f. Unable to score US FORMDROPDOWN C8 PEER/ADULT SOCIAL RELATIONSHIPS (NON-FAMILY) A. Strong social relationships. Child routinely interacts with social groups having positive support and influence, models responsible behavior, participates in constructive age-appropriate activities. Child is actively engaged with a positive support network that is comprised of at least one supportive, caring non-family adult. Child displays age-appropriate solutions to social conflict. B. Adequate social relationships. Child frequently interacts with social groups having positive support and influence; child displays age-appropriate social behavior; frequently participates in positive age-appropriate activities. Child engages with a positive support network. Child frequently displays age-appropriate solutions to social conflict. C. Situational concern. Child has a situational concern with peer/adult relationships as the result of an experience (ex. a new school, change of placement, relationship loss, etc.) that may require additional support. D. Limited social relationships. Child has limited peer/social relationships and limited adult support. Child demonstrates inconsistent social skills. Child has limited positive interactions with others and demonstrates limited ability to resolve conflicts. Child occasionally engages in high risk behavior/activities. E. Severely limited social relationships. Child has severely limited and/or negative peer social relationships, has minimal or lacks non-family adult support, is isolated and lacks access to a support network. Child is unable to resolve social conflict. Child chronically engages in high risk behaviors/activities.  MACROBUTTON [2] "Click Here and Type"  ItemC9.Cultural/Community Identitya. Strong cultural/community identity +3b. Adequate cultural/community identity 0c. Situational concern -1d. Limited cultural/community identity -2e. Disconnected from cultural/community identity -3f. Unable to score US FORMDROPDOWN C9 CULTURAL/COMMUNITY IDENTITY A. Strong cultural/community identity. Child relates positively to his/her cultural, ethnic, and/or religious heritage. Child identifies with and participates in cultural and community heritage, beliefs, and practices. Child expresses age-appropriate inquiries about his/her cultural/community identity. B. Adequate cultural/community identity. Child relates to his/her cultural, ethnic, and/or religious heritage. Child has a developing sense of identity with his/her cultural and community heritage. Child expresses an age-appropriate awareness of his/her cultural/community identity. C. Situational concern. Child has a situational concern related to the development of a positive cultural/community identity, which causes an interruption in progress toward achievement of such an identity. D. Limited cultural/community identity. Child has some conflict with his/her cultural, ethnic, and/or religious heritage. Childs sense of identity with his/her cultural and community heritage is limited. Child does not express an age-appropriate awareness of his/her cultural identity. E. Disconnected from cultural/community identity. Child lacks a sense of identity with his/her cultural and community heritage, or has a sense of identity but his/her understanding of it results in negative self-concept, distorted perceptions about identity, and/or impaired social functioning.  MACROBUTTON [2] "Click Here and Type"  PRIORITY NEEDS AND STRENGTHS:Based on this assessment, identify below up to three priority needs and strengths of the child (indicate item code and title), if three needs have been scored. Priority needs are the top three domains with a negative number and priority strengths may be the domains that score 0 or a positive number. Address all situational concerns and priority items in the Individual Child Activities and Foster Parent/Relative sections of the Parent Agency Treatment Plan and Service Agreement. If a child has an identified need or situational concern in Medical/Physical, Mental Health and Well-Being and/or Education, it must be addressed with services regardless of priority. ASSESSMENT DOMAINSAREAS TO ADDRESS ON ISP/USPC1 Medical/Physical HealthPriority Strengths: (list priority strength areas a and b responses):1. FORMDROPDOWN C2 Mental Health and Well-Being2. FORMDROPDOWN C3 Child Development3. FORMDROPDOWN C4 Family and Kin/Fictive Kin Relationships/AttachmentsPriority Needs: (list priority need areas d and e responses)1. FORMDROPDOWN C5 Education2. FORMDROPDOWN C6 Substance Use3. FORMDROPDOWN C7 Sexual BehaviorC8 Peer/Adult Social RelationshipsSituational Concerns: (list all areas assessed as situational concerns c responses)1. FORMDROPDOWN C9 Cultural/Community Identity2. FORMDROPDOWN 3. FORMDROPDOWN Other Child Strengths Provide information on any other strength for the child not identified in the needs and strengths assessment.  MACROBUTTON [2] "Click Here and Type"   D.Appropriateness of Placement: Based on the child needs assessment, explain why this placement is the most appropriate and least restrictive placement for the child. If the placement is not the least restrictive placement for the child based on the assessed needs, describe the appropriate placement for the child, the services needed to maintain the placement and the reasons for the continuation for residential placement.   MACROBUTTON [1] "Click Here and Type"   E.Prognosis for Placement in Family Setting or Independent Living: What is the prognosis for the child to be able to live in a family setting or independent living? What is the likelihood that the child will be able to live in a family setting or independently following completion of treatment at this facility? Explain how this placement will prepare and assist the child to live in a family setting or to live independently?   MACROBUTTON [1] "Click Here and Type"   F.Parent/Caretaker, Other Significant Individuals Feedback: Provide a summary of any input concerning the childs behavior; history, progress in treatment, etc., from parent/caretakers, siblings or other significant individuals (may be past or projected placements, foster care workers or other treatment providers. Discuss parental or other significant persons support and cooperation with this placement and any barriers they may present to treatment.   MACROBUTTON [1] "Click Here and Type"   G.Progress to Date and Parenting Time: Briefly summarize any changes in the family or the child since the current placement began. Describe current status of child including significant events since placement in this facility. List all visits between the child and others. Identify dates of visits including any missed or cancelled visits by any party. Describe compliance with the parenting time plan and sibling visitation plan, if applicable and any other planned visitation or contacts with appropriate parties. List planned visits for the next planning period under goals and objectives for the child.   MACROBUTTON [1] "Click Here and Type"   V.Family AssessmentThis section must be completed if the child has an identified family with a permanency planning goal of return home or if the placing agency has specified that the child will be placed with a parent. This section is not completed if the child is a permanent ward. The primary caretaker is the adult (typically the parent) living in the household who assumes the most responsibility for child care. When two adult caretakers are present and the worker is in doubt about which one assumes the most child care responsibility, the adult legally responsible for the children involved in the incident should be selected. If this rule does not resolve the question, the legally responsible adult who was a perpetrator should be selected. Only one primary caretaker can be identified in a household. If the child is a permanent ward or MCI and there is not an identified family, click no for the question below Does child have family participation in reunification and or treatment planning? and click on the Remove Family Assessment button. Do not complete the assessment for fictive kin or placement resources for the child unless DHS has identified the placement as a legal guardian or parent. If you need more than one family assessment click here. FORMTEXT      Does child have family participation in reunification and or treatment planning? Yes  FORMCHECKBOX  No  FORMCHECKBOX 1.Family Participation If the youth has an identified family participating in services, provide information on the participation in services. Include any relevant information on changes in the family since the last assessment.   MACROBUTTON [1] "Click Here and Type"  2.Family Assessment of Needs and Strengths Briefly outline the observations and other facts that led to each individual item scored as a need or strength on the Family Assessment of Needs and Strengths for either caretaker. If there is more than one household involved in planning for the child, score both households separately. 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 worker is unable to obtain information at the ISP, Record US for Unable to Score If there are significant discrepancies between facility scoring of any need item and the worker with primary family responsibility, it must be resolved through a conference with the family worker.   MACROBUTTON [1] "Click Here and Type"  Family Name FORMTEXT      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 S1. EMOTIONAL STABILITY BEHAVIOR 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS2.Parenting Skillsa. Strong skills s +2b. Adequate skills 0c. Improvement needed -3d. Destructive/abusive parenting -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS3.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 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. 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS4.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS5.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS6.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS7.Communication/Interpersonal Skillsa. Appropriate skills 0b. Limited or ineffective skills -2c. Isolating/hostile/destructive -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS8.Housinga. Adequate housing 0b. Some housing problems, but correctable -2c. No housing, eviction notice -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S8. HOUSING A. Adequate housing  Family has adequate housing of sufficient size to meet their basic needs. B. Some housing problems, but correctable - Family has housing, but it does not meet the health/safety needs of the children due to such things as inadequate plumbing, heating, wiring, housekeeping, or size. C. No housing, eviction notice  Family has eviction notice, house has been condemned, is uninhabitable, or family has no housing.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS9.Intellectual Capacitya. Average or above functional intelligence 0b. Some impairment, difficulty making skills -2c. Severe limitation -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S9. INTELLECTUAL CAPACITY A. Average or above functional intelligence  Caretaker appears to have average or above average functional intelligence. B. Some impairment, difficulty in decision making skills  Caretaker has limited intellectual and/or cognitive functioning which impairs ability to make sound decisions or to integrate new skills being taught, or to think abstractly. 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).  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS10.Literacya. Literate 0b. Marginally literate -2c. Illiterate -3d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS11.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS12.Employmenta. Employed +1b. No need 0c. Unemployed but looking -1d. Unemployed, not interested -2e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS13.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS14.Child Characteristicsa. 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 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.  MACROBUTTON [1] "Click Here and Type"  Based on this assessment, identify below the priority needs and strength of the family 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 Characteristics3.Family Strengths Provide information on any other strength for the family not identified in the needs and strengths assessment.  MACROBUTTON [1] "Click Here and Type"  PARENT AGENCY TREATMENT PLAN AND SERVICE AGREEMENT This treatment plan is developed to assure that each child will receive safe and proper care and services by the following activities.A. SERVICE REFERRAL TABLEBarrier/Needs Addressed C1 = Medical/Physical Health C2 = Mental Health and Well Being C3 = Child Development C4 = Family and Kin/Fictive Kin Relationships/Attachments C5 = Education C6 = Substance Use C7 = Sexual Behavior C8 = Peer/Adult Social Relationships (Non-Family) C9 = Cultural Community Identity S1 = Emotional Stability S2 = Parenting Skills S3 = Substance Abuse S4 = Sexual Abuse S5 = Domestic Relations S6 = Social Support System S7 = Communication/Interpersonal Skills S8 = Housing S9 = Intellectual Capacity S10 = Literacy S11 = Resource Availability/Management S12 = Employment S13 = Physical Health Issues S14 = Child CharacteristicsService Referral Type Codes AD = Alcohol / Drug Abuse Rehabilitation DC = Day Care DV = Domestic Violence ED = Education FC = Family / Outreach Counseling FR = Reunification Services HS = Homemaker Services or Parent Aid IL = Independent Living JT = Job Training MD = Medical ServicesMH = Mental Health Services OT = Other Program Needs PS = Parenting Skills Training TH = Individual / Group Therapy WP = Wrap Around Family Member Name Barriers/ Needs Addressed  Service Type Code  Service Provider Name  Mo/Yr Re- ferred  Mo/Yr Start Target Com- pletion Date (Mo/Yr) Service Status  Completed Services  Com- pletion Date (Mo/Yr)  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       Parent - Agency Treatment Plan and Service Agreement (continued) In this section, provide the specific goals, objectives, activities, and parenting time (schedule and expected activities), sibling visitation and other activities for all parties, the placement provider, the child, and the foster care worker. The goals and objectives must be clear, measurable, with expected outcomes to assist the child to live in the least restrictive setting possible.B. Child Goals, Objectives and Expected Outcomes 1. List childs service goals and action steps (include time frames and responsibility). Goals should address areas prioritized on Child Needs and Strengths Assessment and activities of daily living (if applicable). Identify what agency and parent(s) need to do to meet these specific needs. 2. If the child is age 14 or older (including those wards who become 14 years of age during the report period), include a description of the programs and services which will assist the youth to prepare for the transition to a state of functional independence or the ability to take care of oneself physically, socially, economically and psychologically and identify where, how and by whom these services are to be provided.   MACROBUTTON [b2] "Click Here and Type"   C. Parent Activities - If child is permanent ward or has no participating parent, write NA 1. List each goal for parent(s) and non-parent adult(s), if applicable, specific action steps, time frame for achieving, and expected outcome. Goals must address the areas prioritized on the Family Assessment of Needs and Strength. If applicable, specify involvement in medical and dental appointments, attendance at school conferences and in treatment with the child. Identify how the facility will coordinate the activities with the supervising agency. 2. Indicate if employment, day care, and/or transportation is a barrier to the parent meeting any of the goals or action steps including parenting time. Indicate the plan to address any of these three items.   MACROBUTTON [b2] "Click Here and Type"   D. Residential Care Treatment Activities 1. Identify clinical services to be provided to the child and family and all other parties, as appropriate. This includes any other potential placement for the child. 2. Identify day to day activities completed by facility staff. 3. State proposed residential worker contact with the child and family, if applicable. 4. For each ward age 14 or older (including those wards who become 14 years of age during the report period), include a description of the programs and services which will assist the youth to prepare for the transition to a state of functional independence or the ability to take care of oneself physically, socially, economically and psychologically. Identify where, how and by whom these services are to be provided. (See CFF 722-6 Independent Living Preparation.)   MACROBUTTON [b2] "Click Here and Type"   E. Parenting Time Identify under worker activities what the agency will do to facilitate parenting time. Identify here what the parent must do during parenting time with the child. If there is no parent, Write NA) in the space provided below. 1. Specify type, frequency, location, and duration of parenting time. If less than weekly, specify why. 2. If agency is limiting parenting time, specify why more frequent would be harmful to the child and what parent must do to achieve at least weekly parenting time. If parent is limiting, indicate parents reasons for wanting less frequent visits and project if and when frequency could be increased. 3. State how parenting time setting will assure a family friendly environment. If location is other than parental home, specify where and what conditions must exist for in-home visits to take place. 4. If parenting time is supervised, specify by whom and what conditions must exist for unsupervised visit. 5. Specify length of parenting time. 6. Specify expected activity during parenting time by all participants.   MACROBUTTON [b2] "Click Here and Type"   F. Visitation with Siblings and Others Identify under worker activities what the agency will do to facilitate time with siblings and others as appropriate. Identify the goals and objectives of the visits. 1. Specify type, frequency, location, and duration of visitation with siblings or others. Specify the name of the visitor and relationship to the child. 2. If visitation is supervised, specify by whom and what conditions must exist for unsupervised visit. 3. Specify length of visitation and the location of the visit. 4. Specify behaviorally specific activity expected by all parties during the visitation.   MACROBUTTON [b2] "Click Here and Type"   The development of this plan was negotiated with (also list those individuals who were unavailable to participate in the development and why not): Indicate who the plan was negotiated with and any individual who is involved in the plan but was unavailable to participate in its development. 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(See CFF 722-6, Parental Involvement in Developing the Plan.) Youth age 14 and older must be involved in the development of the plan and be responsible for its implementation with the assistance of identified individuals.   MACROBUTTON [b2] "Click Here and Type"   By signing below I agree that I have read the above, discussed it with my residential care worker, and understand what is expected of me to facilitate the permanency planning goal.CLICK HERE TO ADD YOUTH SIGNATURE FOR YOUTH AGE 14 AND OLDER  FORMTEXT       Parent/Caretaker Name:  FORMTEXT        Parent/Caretaker Signature:  Date: By signing below on behalf of the Department of Human Services we agree to those activities outlined above and will assist the family in their efforts to facilitate the Permanency Planning goal. Name and Title:  FORMTEXT       Signature: Date: Distribution of Plan:   MACROBUTTON [b2] "Click Here and Type"   DHS Local Office Name:  FORMTEXT      DHS Local Office Approval: Signature:  Date:  Title:  FORMTEXT       Date:  FORMTEXT       The local office shall approve, or disapprove, in writing, the Initial Service Plan for a child in purchased foster care or residential care. The Purchase of Service Agency is responsible for all elements of the Service Plans in cases where they have accepted responsibility for providing family services per the DHS-3600 contract. The local office is responsible for reporting requirements only when the Purchase of Service Agency has not accepted total case responsibility. The report from the local office should not duplicate the Purchase of Service agency report, but should address those areas for which the Purchase of Service Agency is not responsible per the DHS-3600 contract. Approval shall be indicated by signing the Initial Service Plan submitted by the purchase agency. The approved Initial Service Plan is to be returned to the purchase agency within seven days of receipt; a copy is retained in the child's case record. The local office is responsible for knowing what services are being purchased from the purchase agency and for monitoring compliance with the DHS-3600. When a noncompliance situation is identified, it is to be brought to the attention of the purchase agency both verbally and in writing. If efforts to resolve the area of conflict locally are not successful, the situation is to be brought to the attention of the appropriate Zone Office. If they are unable to intervene successfully, then Office of Child and Family Services is to be involved. ?Y@YAYBYmYnYoYpYJZ)v:))|2kdq@$$Ifl|))4 la$If$a$5kd"@$$Ifl4|))4 laf4 $$Ifa$$If JZLZZZZ ["[J[L[N[P[rll jll jaNj[ljlv:lv:$If d$If$IfJkdA$$Ifl4))  4 laf4p x$If:kd@$$Ifl4))4 laf4 ZZZZZZZZZZ[ ["[$[8[:[<[F[H[J[L[R[T[[[[[[[[[$\,].]T]V]j]󾺰wodhg5CJOJQJh|/hk@"5jhU5UmHnHujBh$#h$#5U h$#5jh$#5Uhk@"5CJOJQJhk@"CJOJQJhk@"hk@"B*ph#jhUB*UmHnHphu$j Ah$#h$#B*Uphh$#B*phjh$#B*Uph$P[R[T[[[[[[[[l jl |NjyNjjv:v:$If$If$IfskdB$$Ifl4\ ")D &4 laf4 [[[[.])v:JA $$Ifa$:kdD$$Ifl4))4 laf4$IfskdpC$$Ifl4\ ")D &4 laf4.]0]2]R]T]|]~]] v: |v:v:$If$If$If:kdlD$$Ifl4))4 laf4j]l]n]x]z]|]]]]]] ^6^8^:^B^D^J^n^r^t^v^^^^^^^^^^^^^^^_ _____ _"_6_8_:_ˮ˦ˮ˶斆϶˶˶vjVJh$#h$#5UjGh$#h$#5U h$#5h5CJOJQJhk@"B*phjhk@"Uhk@"CJOJQJhk@"5CJOJQJhk@"h|/hk@"5jhU5UmHnHujh$#5UjDh$#h$#5U.]]]]]]]]] | ||||||$IfskdE$$Ifl4\2 ") 4 laf4]]]]]])v:J)j)j:kdF$$Ifl4))4 laf4$Ifskd,F$$Ifl4\2 ") 4 laf4]]]<^>^@^B^D^r^t^^^^)~ j~ j~j~j$If7kdwG$$Ifl|))4 la$If:kd(G$$Ifl4))4 laf4 ^^^^^)jL)j9kdI$$Iflh$*)4 la$Ifrkd`H$$Iflh\$ #* 4 la^^^^^^^_ _ _jjjjjjjj$If9kdTI$$Iflh$*)4 la ____ _H_J_V_X_Z_.j.jy!sjjjj$If 6d$$If$IfrkdI$$Iflh\$ #*4 la :_D_F_H_J_T_Z_\_^_r_t_v______Q`R``aaaabdbsbtbbbcddddddd'e(ee模uuukiUhk@"<B*phh.hg<B* phh.h-<B* phh.hk@"<B* ph hk@"5 hk@"5CJhk@"hk@"5jKh$#h$#5U h$#5hk@"hk@"5CJOJQJhk@"CJOJQJh|/hk@"5jh$#5UjhU5UmHnHu(Z_\___)$IfrkdK$$Iflh\$* #*4 la__ocpceeЉvv $If^ $If^ $$Ifa$Z^ZckdhL$$Ifl4h$*)04 laf4 Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, 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 DHS-366 (Rev. 7-09) Previous edition obsolete. 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l)5555H5A5M4avp<$$Ifv!vh5555H5A5M#v#v#v#vH#vA#vM:V l)5555H5A5M4avp<$$Ifv!vh5555H5A5M#v#v#v#vH#vA#vM:V l)5555H5A5M4avp<$$Ifv!vh5555H5A5M#v#v#v#vH#vA#vM:V l)5555H5A5M4avp<$$Ifv!vh5555H5A5M#v#v#v#vH#vA#vM:V l)5555H5A5M4avp<$$Ifv!vh5555H5A5M#v#v#v#vH#vA#vM:V l)5555H5A5M4avp< Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US&$$Ifv!v h555555555 #v#v#v#v#v#v#v#v#v :V l)555555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. 0-3-4-5US Df;Select most serious score between two caretakers in family. 0-3-4-5US Df;Select most serious score between two caretakers in family. 0-3-4-5US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l)555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l)555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l)555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l)555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. 0-1-2-3US Df;Select most serious score between two caretakers in family. 0-1-2-3US Df;Select most serious score between two caretakers in family. 0-1-2-3US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4azL$$Ifz!vh5)#v):V l")5)4azL$$Ifz!vh5)#v):V l")5)4azDText4Enter household name.$$Ifz!vh5555T5 #v#v#v#vT#v :V l4 "),5555T5 4azf4$$Ifz!vh55555 #v#v#v#v#v :V l4")55555 4azf4JDf9Select first of top three priority needs for household 1. 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9 years)comp martinezl|                       P@PNormal'CJ OJPJQJOh+'0 , @L h t  PDHS-0366, Children's Foster Care Residential Updated Service Plan (4 - 9 years)comp 0366.dot martinezl107Microsoft Word 10.0@@4W@^@4W%՜.+,0H hp  (State of Michigan{ PDHS-0366, Children's Foster Care Residential Updated Service Plan (4 - 9 years) Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCEFGHIJKMNOPQRS^_t{bcdefrhijklmnopqsuvwxyz|}~Root Entry FWa@[Data OI1TableWordDocumenty$SummaryInformation(DDocumentSummaryInformation8LMacros>W$AWVBA>W$AWdirYModule1 __SRP_0g__SRP_1 /  !"#$%&'()*+,-.0123456789:;<=?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`bcdefghjklmnopqrstuvwxyz{|}~U0* pHdTemplateProjectQH@  = | 9K J< 9stdole>stdoleP h%^*\G{00020430-C 0046}#2.0#0#C:\WINDOWS\system32\e2.tlb#OLE Automation0MSForms>SFFrms3ED452EE1-E08F-101A-8-02608C4D0BB4EFM20.DLL#Microsoft : ^ Ob Library/;D~1u00}#0#k0 B11B0288-DD3E-49B5-A37E-2A97CC021D66DOCUME~1\bushd2\LOCALS\VBE\T.exd;@!.E .`M OfficOf@ic 12DF8D04C-5BFAgB-BDER5IAA42ggram Files\CommonhShared\ 105Op 8.0p@% [n»ThisDocumentG T@i"Dcuen@ 2 (HB1XB,!;Tr""+`nAddHeadDialogG*@Ard ea Dilg I2\/F m-! % NewMbaAfG ?wDM`crs2/Jo# +!PopUBpFmpt25PpUpPm ta 5o`"B0zZ3y3#l3y3opkB@SvcRefHindHSv`uR`6f&Ii@[eHJcHW/ /8,[FamAssess%[FHmA os@s#n%oKoh%YaSaveG~tJS v`i2rou@Gk Module1Goo=uw1"f2!r`] Yl[n xME(<$<< <x   "Xj%Xh9K "  .@Pp &x  (((P X h]@'If document is protected, Unprotect it.00 >!& (cladd87L >B@@DHS FokPerform Spelling/Grammar check.d *(,er " >!.ws "!(0V4 "!B@2si " ReProtect the document. >!& (cladd87LN Pl >B@JkoAttribute VB_Name = "Module1" Sub FormsSpellCheck2() Dim x As wdNo Then  9ZPassword:="c@ladd87E nd If'P(erf ing/Gramma8r clK.Op2tBs.vWi thFalse EachIn JsZx.Range.iof>$;;5AlwaysSuggest :=Tru; Next: 'Re the=&EW, n orese&, o:=wdAllowOnlyAbAAerU~} K*srU~~~~~~~~~~~~~~~~~~~~A 7@Fg[tN   Q%a a   1Qy 9 AaA a yiIATemplateProject ThisDocument AddHeadDialog NewMacros PopUpPrompt2 PopUpPrompt3 SvcRefHeadingF /C:\PROGRA~1\COMMON~1\MICROS~1\VBA\VBA6\VBE6.DLLVBA  i0 F5C:\Program Files\Microsoft Office\Office10\MSWORD.OLBWord q@0FC:\WINNT\System32\StdOle2.Tlbstdole  QP.E .`M C:\WINDOWS\System32\FM20.DLLMSForms 1`G6]@}fj"4U 2C:\DOCUME~1\MARTIN~1\LOCALS~1\Temp\VBE\MSForms.exd 1pL-[DR 2C:\Program Files\Microsoft Office\Office\MSO97.DLLOffice )RemoveTableRowPromptAddParentRowsFamilyPartNoMSG DeleteFAN AddSvcRefRowAddParentSignatureAddYouthSignaturePromptNameTitleAddNameTitleSignature AddParentRows  ZYou MUST Save This Document Before Continuing 2Select Save In Folder and HEnter File Name in SaveAs Dialog Box F Fi k Fu Fp F YouthSignatureAutoTextEntries WhereRichText Insert fĤIx8< Error In Case InfoVBE6.DLL ` i  S Module1 AddFamAssess PThere is already ONE Family Assessment.   " How many ADDITIONAL Family Assessments are needed for this form? TExample: {Total adults being reported = 3} j { Minus existing = 1}  j { Enter additional = 2} *CANCEL or ESC if none .IDENTIFYING INFORMATION NewAssess Yes 0 AddFamilyAssess T 0AutoSave JCheck if Ethnicity Hispanic or Latino Dand Click 'Add Parent Rows' Button 0to add Additional Parent @If NO LEGAL FAMILY, enter X and, NClick 'Remove Family Assessment' Button on Toolbar to <Delete Family Needs AssessmentMAIN 0Add Service Referral RowBeginDialog d**To Add Additional Row(s) for Service Referrals**Text @After entering Completion Date,  NClick ADD SVC REF ROW Button on ToolbarOKButtonCancelButtonEndDialogCurValuesUserDialog Dialog AddSvcRefRow HAdd Additional Parent Signature Rows d**To Add Additional Row(s) for Parent Signatures** LAfter completing Parent's Name entry,  `Click Add Parent Signature Button on the Toolbar RTo add Additional Name and Signature Rows 8Click 'Add Name Rows' ButtonƇJFn5 F:cMHYwH FDocument @ $AddParentSignature *AddNameTitleSignature AddParentRows cladd87b F` F F F family history F   %Macro recorded 03/03/00 by Sandy Cain (TemplateProject.NewMacros.RemoveTableRow %Macro recorded 08/21/00 by Sandy Cain -TemplateProject.NewMacros.PromptAddParentRows %Macro recorded 08/22/00 by Sandy Cain )TemplateProject.NewMacros.FamilyPartNoMSG #TemplateProject.NewMacros.DeleteFAN %Macro recorded 08/24/00 by Sandy Cain +TemplateProject.NewMacros.AddYouthSignature )TemplateProject.NewMacros.PromptNameTitle %Macro recorded 08/25/00 by Sandy Cain /TemplateProject.NewMacros.AddNameTitleSignature 'TemplateProject.NewMacros.AddParentRows -View instructions for using FIA-#### buttons. !TemplateProject.PopUpPrompt2.MAIN !TemplateProject.PopUpPrompt3.MAIN  %7rU~|   9I  __SRP_2>__SRP_3 a__SRP_4i__SRP_5 g&&&' )'Q'i ' 1 0  0  0 H  XK:\ l lL < <,:    :`16lL<, $ 4 ):\Nll$ 4 5lp$ 8 (  H  @ k$ 8 (  H  D ) 9$ 8 (  H  D )*$ <  )$$ < Q    D  ,    H  `  P  X  @ c{'x'''''''''' ','<'L'l$ <  )6lL<, x<$ 8 (  H  , )<t<(Ll$ <  6lL<2t(Ll$ <  6lL<$ 8 (  H  , )5:\NllcL$ 4 6lL$t  ltfE&'<'L'lM\@ 6lL< mp  ,t  ','<lt#l*#h*FL0>pFl 2lh)6lL<, ,lplhlL<, x0   0   0   0   0 @  0    >rU $`a$`q$`1$`$!`$I`$q`9$`$` a$ ` nrU~| 9Y  i   !1 9 A   1 K" h  8      x  X 'H'h''(:N*#x*F:XhH8(:::xhXH:8( F(8/x60hH8(xhXH(hH 83N):X Nhh $ 4  5hF:NHH'('8h $ <  )6hH8(2 (Hh $ <  6hH5:X NhhcH $ 4  6hHF:NHH'('8h $ <  )6hH8(8:X]3):X Nhh $ 4  5hF:NHH'('8h $ <  )6hH8(2 (Hh $ <  6hH5:X NhhcH $ 4  6hHF:NHH'('8h $ <  )6hH8( $ 4  ):X Nhh $ 4  5hF:NHH'('8h $ <  )6hH8( $   |o $ <  QoH%c%:X%h $ 4  Xh>()6hH(F:NHH'('8h $ <  )6hH8(5:X NhhcH $ 4  6hH$  l fu&'8'H'hMX@ 6hH8 mx  ,  '('8l #*#*FH0>xFh 2)6hH8( 08xhH8(xhXH(hH(krU $`nrU $$$ 4 %)1%0`rU @n__SRP_c__SRP_dBAutoSaveNewMacros4\o[nxME(< <<<X `x@8x% (x4x ^P9K " . 8HX( Macro copied from one of Sandy's 2/8/06% >B@dHo0(Attribute VB_Name = "AutoSave" Sub 8() ' Macro copied from one of Sandy's 2/8/ 06 ActiveDocu ment. End T[ [nB0xMEJ [nxME(@6 <<<< <<<<< <$LL*LLLLLLL <`@p| %Macro recorded 03/03/00 by Sandy Cainbuttons(TemplateProject.NewMacros.RemoveTableRow RH`J %Macro recorded 08/21/00 by Sandy Cain-TemplateProject.NewMacros.PromptAddParentRows \`J %Macro recorded 08/22/00 by Sandy Cain)TemplateProject.NewMacros.FamilyPartNoMSG ``(Xxho.. %Macro recorded 08/22/00 by Sandy Cain#TemplateProject.NewMacros.DeleteFAN `|N!!N `|N**o `@p|N!!%Macro recorded 08/24/00 by Sandy Cain+TemplateProject.NewMacros.AddYouthSignature @`J %Macro recorded 08/24/00 by Sandy Cain)TemplateProject.NewMacros.PromptNameTitle `|N--%Macro recorded 08/25/00 by Sandy Cain/TemplateProject.NewMacros.AddNameTitleSignature  `(X|N !!%Macro recorded 08/25/00 by Sandy Cain'TemplateProject.NewMacros.AddParentRowsH@:%H@H@h0 0H @  X V>fBx@`l @\ @xL @< @, @8 @ @ @ @  @P @h @( PT@ @ @ @ x \%@ @( @ `@  @ x @ h @ X @ H @ 8 @ ( @  @@  @X @p @ @ @ @ @ @ @x @t P^XZ@H p @` l @h   @ @ @ @ P @ P (@ @ X @ @ @x XZ @t @p @l PBP.N8l itle@\ tle `@L ded @< in @, Add@ natup "Cl@ Butt@ @ xcla@ Sub@ re()P@ itleP(tion@ 8/25@ AttrX gnat@ nvok@ ojec@x itle XZ' ' Addme@t ' @p /00 @l * pHXstem32\Stlel on@\ S0L 452E@< 0260(, 20.D( Ob@ t@ k00PBP8l @\ @L @< @, @ Ppp @ @ @ @ @ @ (@ @ HX @ @ @x 8Z@t @p @l 0PBP8l @\ @L @< @, @ pp @ @ @ @ @ @ (@ @ HX @ @ @x 8XZ@t @p @l 0PBP8l @\ @L @< @, @ pp @ @ @ @ @ @ (@ @ HX @ @ @x 8XZ@t @p @l  89K $*\Rffff*0I4b3f5f4a*\R0*#14*\R0*#1*\R0*#19*\R0*#1a*\R0*#13*\R1*#91*\R1*#1a7*\R1*#a4*\R1*#1e*\R1*#71*\R1*#b5*\R1*#d7*\R1*#d6*\R1*#129*\R1*#158*\R1*#d2*\R1*#d0*\R1*#c6*\R1*#c1*\R1*#17b*\R0*#f"   ,0 `` hx0 "  ,T  & "    , 0w8  & "  ( 0 ,H x  8  P)*p`9* $         (0{8<H"<`2< @5 &$&.@8mH6"    , (0 8   7 0 @>oP27 @ &$& . P 8mX 6   "  , 8 @ H    X7  @  P Do 2 7 Hp D . H D $H &p @H  @  &$ & .0 ` 8mh 6    "   , HP X    x50 H X@oh27 @0 &$&(.8h8mp6 "    ,  Pt1X & "   " ,  PX `   (585P5h5555  Ho27  H D .` H@ D & @5@X@p` h&$p&.8m6PX" ` h p ,     85  @o2 7@ `@h p&$x&.8m6 X ` RemoveTableRow MacroB@ & Macro recorded 03/03/00 by Sandy Cain BB@Dx B!FB@Hcladd87L >B@@l o8 PromptAddParentRows Macro& Macro recorded 08/21/00 by Sandy Cain%Check if Ethnicity Hispanic or Latino $V "and Click 'Add Parent Rows' Button $V to add Additional Parent ' T Define prompt T ZA@XoH FamilyPartNoMSG Macro& Macro recorded 08/22/00 by Sandy Cain If NO LEGAL FAMILY, enter X and, $V 'Click 'Remove Family Assessment' Button $V on Toolbar to $V Delete Family Needs Assessment ' T Define prompt T ^A@Xo DeleteFAN Macro& Macro recorded 08/22/00 by Sandy Cainb`-You MUST Save This Document Before Continuing $V $V Select Save In Folder and $V $V $Enter File Name in SaveAs Dialog Box ' T Define prompt >B@d f!h!j!l f!h!j(l f!h!j(l B!nB@p B!nfamily history9d5r(d9t x9v99z9|9~99q B!nB@  f!h!j(l   BB@  BB@H  f!h!j(l|b fsave file cancelled T ^A@X #return to point of error in routinedX ! ZError ! In Case InfoA@X+Reprotect Document and exit sub after errorko AddSvcRefRow Macro& Macro recorded 03/27/00 by Sandy Cainbh-You MUST Save This Document Before Continuing $V $V Select Save In Folder and $V $V $Enter File Name in SaveAs Dialog Box ' T Define prompt >B@d  BB@ BB@ (  B! AddSvcRefRow >!%B@  BB@H  BB@|xbp fsave file cancelled T ^A@X #return to point of error in routined ! ZError ! In Case InfoA@X+Reprotect Document and exit sub after errorko AddParentSignature Macro& Macro recorded 04/06/00 by Sandy Cainb-You MUST Save This Document Before Continuing $V $V Select Save In Folder and $V $V $Enter File Name in SaveAs Dialog Box ' T Define prompt >B@d  BB@ BB@ ('Selection.MoveUp Unit:=wdLine, Count:=1!  BB@H  BB@( Selection.MoveUp Unit:=wdLine, Count:=1=Selection.Style = ActiveDocument.Styles("Captions 9pt Bold") Selection.Font.Bold = wdToggle  Selection.MoveRight Unit:=wdCell  B!AddParentSignature >!%B@P|b fsave file cancelled T ^A@X #return to point of error in routined ! ZError ! In Case InfoA@X+Reprotect Document and exit sub after errork o AddYouthSignature Macro& Macro recorded 08/24/00 by Sandy Cainb-You MUST Save This Document Before Continuing $V $V Select Save In Folder and $V $V $Enter File Name in SaveAs Dialog Box ' T Define prompt >B@d  BB@ BB@ (  B!YouthSignature >!%B@  BB@H  BB@|b fsave file cancelled T ^A@X #return to point of error in routinedH ! ZError ! In Case InfoA@X+Reprotect Document and exit sub after errork o  PromptNameTitle Macro& Macro recorded 08/24/00 by Sandy Cain)To add Additional Name and Signature Rows $V Click 'Add Name Rows' Button ' Ta Define prompt T ZA@Xo @ AddNameTitleSignature Macro& Macro recorded 08/25/00 by Sandy CainbX -You MUST Save This Document Before Continuing $V $V Select Save In Folder and $V $V $Enter File Name in SaveAs Dialog Box ' T Define prompt >B@d  BB@  BB@  BB@  BB@  BB@  BB@  BB@ BB@ (  BB@H  BB@BSelection.MoveRight Unit:=wdCharacter, Count:=15, Extend:=wdExtend>'Selection.Style = ActiveDocument.Styles("Captions 9pt Bold")B@ Selection.MoveRight Unit:=wdCell  B!AddNameTitleSignature >!%B@  BB@ |b fsave file cancelled T ^A@X #return to point of error in routinedH ! ZError ! In Case InfoA@X+Reprotect Document and exit sub after errorko AddParentRows Macro& Macro recorded 08/25/00 by Sandy CainbX-You MUST Save This Document Before Continuing $V $V Select Save In Folder and $V $V $Enter File Name in SaveAs Dialog Box ' T Define prompt >B@d  BB@ BB@ (  B! AddParentRows >!%B@  BB@H  BB@|pbh fsave file cancelled T ^A@X #return to point of error in routined ! ZError ! In Case InfoA@X+Reprotect Document and exit sub after errorkoxpBSelection.MoveRight Unit:=wdCharacter, Count:=31, Extend:=wdExtend=Selection.Style = ActiveDocument.Styles("Captions 9pt Bold")esBSelection.MoveRight Unit:=wdCharacter, Count:=23, Extend:=wdExtend:Selection.Style = ActiveDocument.Styles("User Input 11pt")BSelection.MoveRight Unit:=wdCharacter, Count:=14, Extend:=wdExtend=Selection.Style = ActiveDocument.Styles("Captions 9pt Bold")sv:Selection.Style = ActiveDocument.Styles("User Input 11pt")cladd87L >B@@ cladd87LN Pl >B@Jcladd87LN Pl >B@J[reprotect documentcladd87LN Pl >B@J[reprotect documentcladd87LN Pl >B@J[reprotect documentcladd87LN Pl >B@J[reprotect documentcladd87LN Pl >B@J[reprotect documentcladd87LN Pl >B@J[reprotect documentcladd87L >B@@ $cladd87L >B@@cladd87L >B@@$cladd87L >B@@@߶cladd87L >B@@0Attribute VB_Name = "NewMacros" Sub RemoveTableRow()  6.Description recorde d 03/0 by Sandy` CainhRProcData^Invoke_Func^Template"jec4t.. a' '  "S ActiveDocument.Unprot? Passwt:="cladd87<Sel.% s.Dte2q1, noreset:=True, Type:= _$@wdAllowOnlyFormFields End Sub|mptAddPar@8&} 8/21/0oSׂR- $ACheck if Ethnicity Hispa or Latino" + Chr(10)@" Cli 'Y@Z AZ' Button to @ ial 4Define m uMsgBox ), vbExm#onJ|Family=tNoMSG=?=0`&2;=p @> =&<?s???ҠL?vb?& ??i 1hgi?i`th*ipIr8ibuAG.VB_v)"Mji8/2 ji`]_FQ`$cDataInvoke_FuncQ j g.NewBs. cAstt att# t3 ttuttxt}tt T2B=t(__FHWotototot#.%otjt;, tdstttud ttBoh9VhP'VV Qp/? Vrrrʣ0VpBATitlrPP/Vro/V+*V?_ VnVctV|UlUUInd#>$SU ,AАonXal &b Rows"Click '^!' Button" o#(yƌ?Va/ureOr/25~JݴB_ProcData.VB_Invoke_Func = "Tem plateject.NewMacros.AddNameTitleSignatu@re" ' 8 r< recorded 08/25/00 by Sandy Cain( On Error GoTo Hle mpt$You MUST?ve This Document Before Continuing" + Chr(10) "Selr!In Fol0der :EntFile ( inA?ialog BoxDefine p,roX] ActiveS.Save  UntLPassw:="cladd87.\ion.MoveRight Unit:=wdCell+%8SplitPTablEUpcDatADisy AutoCdlet@psTruSaAttache d.Textries("R`"). __jInsert Wh ere:=dRange, Rich:=! 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ZError ! In Case InfoA@X+Reprotect Document and exit sub after errork`oXPcladd87L >B@@nt andcladd87LN Pl >B@J[reprotect documentcladd87LN Pl >B@J[reprotect documentjActiveDocument.Protect Password:="cladd87", NoReset:=True, Type:=wdAllowOnlyFormFields 'reprotect documentcladd87LN Pl >B@J[reprotect document0 Assess BB@ Attribute VB_Name = "AddFamAssess" Sub  H() ' Macro recorded 01/11/01 by Program Area, modify 2/13/07 Diane Bush to add ajmentW On Error GoTo HandlewnumrowsInputBox("There is alpdy ONE 0ily [. " & vbCr"How manDDITIO8NAL,/neesfLth6m?" + Ch r(10)"Example: @{Totalsults beinBgport=H 3} !" {Minus exist&= 1!Enter ition@'= 25"CANCEL =ESC if none", "IDENTIFYING INFORMAP0Èmpt$k"You MUST Save T!PDocuf BeRe Con4u4VUSelectIn Fol2d2ndV :FiHle ·inBAslog @ 'Defipro@, A]CI;ƜcmdCanc$el@0enActive3.UnUtA)Pw:="cl87C1@^.BWha t:=wdBookmark,B+@NewFDBUniBCha(racu,Run]1'dU', ;rese`True@, Type!AllowOnlyFormFiel@ds 'red9 Ye!A"!ExitH`y2C# Else0"d0"/t //"//C///z"/ /@0]A("").Res`~H75?#:F:404P  p0 < 210 "P 4x]DEFINE DIALOG BOXFpAdd Service Referral Row B@,03  2**To Add Additional Row(s) for Service Referrals** B@d;  After entering Completion Date, B@dai;0 'Click ADD SVC REF ROW Button on Toolbar B@dPr^RN B@.\RX B@ B@0 ]F !4!6.2226GET USER INFO FROM INI FILE AND PUT IT INTO DIALOG BOXPart,DISPLAY DIALOG BOX AND RESPOND TO USER INPUT 2 !8%6'  OK BUTTONGet user info from INI file. Update other Form Fields on Form & Exit MacrodHk@o80Attribute VB_Name = "PopUpPrompt2" Public Sub MAIN()  ".zDescriptionView in struc&s for using FIA-# tons.ePcData\Invoke_Func\Template"jec4t. .PDi@m iRet'DEFINE DIALOG BOX WordBasic.BeginDialog 582, 11"Add Service Referral R4ow- Text 90, 5013, "`**To !ic(s),s**,5,3G,After enKCle0 ee= P#4 8PCk ADD SVC REF ROW Bu td @qToolHbar%OK35;L721@Cancel 4 8 I`End_ mdlgUs erInf@Ps Oby:ct = `CurVa`lues.A 'GET USER INFO PFROM@ILE AND PUT INTODISPLAYB RESPO@  $!#(/If§ -1 Then 'OK BUTTONGet5ziBf.file@' Upd othForm Fieldsn& Exit Macro Els @Z If@nub T[ [n     !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWYZ[\]^_`abcdfghijlxME(<< <<( `@x@-View instructions for using FIA-#### buttons.!TemplateProject.PopUpPrompt3.MAIN* @l `2 ompl %HP+0h an@X IN@H m3@8 IN@( m3@ IS@ l\@ c:@ il@ Fi@ c ( te@ am 9K  " :.(P:hD:N:4P4p  0 < 218P "p 4]DEFINE DIALOG BOXFp$Add Additional Parent Signature Rows B@,A-####  2**To Add Additional Row(s) for Parent Signatures** B@d;  &After completing Parent's Name entry, B@d;0 0Click Add Parent Signature Button on the Toolbar B@dA-^RN B@. RX B@F B@0 Tool ]F !4!6.2 6GET USER INFO FROM INI FILE AND PUT IT INTO DIALOG BOX,DISPLAY DIALOG BOX AND RESPOND TO USER INPUTn on F 2 !8%6'  OK BUTTONhaGet user info from INI filebar . Update other Form Fields on Form & Exit Macroscred(k o޲Attribute VB_Name = "PopUpPrompt3" Public Sub MAIN()  ".zDescriptionView in struc&s for using FIA-# tons.ePcData\Invoke_Func\Template"jec4t. .PDi@m iRet'DEFINE DIALOG BOX WordBasic.BeginDialog 582, 11A"Add i^al Parent Signature Rows3 %Text 9!0, 5013, "*8*To%'(sF) -s**,5 ,3M,After clet1%'s Xry@ S&48)Cyk*$ Bu tj wthe ToolbarN)dOK 35>R7 21Cancel 4 8 gHEndf AtdlgUserInBfTs Ob: Set= dCurValue s.A 'GET USER INFO FRO M@I@LE AND PUT I1NTOJDI`SPLAYB RESPO@ | $!#(35@If -1 Then 'OK BUTTONu³G;uA@BfC.file@' HUpd@ ojr Form Fi0eldso& Exit Macro Els - IfndA} Dr[n;r#<ƇJFn5 F:cMHYwHx:cMHYwHƇJFn5ME(SLSS6"N0{00020906-0000-0000-C000-000000000046}(%H@h % %Xp@@09K $*\Rffff*0>47b2d0834xAttribute VB_Name = "ThisDocument" Bas0{00020P906-0C$0046} |GlobalSpacFalse dCreatablPredeclaIdTru BExposeTemplateDerivBustomizD2\c [nx_VBA_PROJECTAddHeadDialogSvcRefHeadingPROJECTXas  *\G{000204EF-0000-0000-C000-000000000046}#4.0#9#C:\Program Files\Common Files\Microsoft Shared\VBA\VBA6\VBE6.DLL#Visual Basic For Applications*\G{00020905-0000-0000-C000-000000000046}#8.2#0#C:\Program Files\Microsoft Office\Office10\MSWORD.OLB#Microsoft Word 10.0 Object Library*\G{00020430-0000-0000-C000-000000000046}#2.0#0#C:\WINDOWS\system32\stdole2.tlb#OLE Automation*\G{0D452EE1-E08F-101A-852E-02608C4D0BB4}#2.0#0#C:\WINDOWS\system32\FM20.DLL#Microsoft Forms 2.0 Object Library*\G{011B0288-DD3E-49B5-A37E-2A97CC021D64}#2.0#0#C:\DOCUME~1\bushd2\LOCALS~1\Temp\VBE\MSForms.exd#Microsoft Forms 2.0 Object Library.E .`M &*\G{2DF8D04C-5BFA-101B-BDE5-00AA0044DE52}#2.2#0#C:\Program Files\Common Files\Microsoft Shared\Office10\MSO.DLL#Microsoft Office 8.0 Object Library   9K [n ThisDocument0>47b2d083ThisDocument;rAddHeadDialog074b39c7a8AddHeadDialog NewMacros0I4b3f5f4a:NewMacros0JPopUpPrompt20:4b39c7a8PopUpPrompt2B0H PopUpPrompt30<4b39c7a8PopUpPrompt3` SvcRefHeading0=4b39c7a8SvcRefHeadingx AddFamAssess0D4788a06a AddFamAssesshKAutoSave0?4b39c7a8AutoSaveuModule1064b39c6ebModule1 rx0`Hl'LEu"y`/CF`B'хn;OEDJL 8pN:R8@R>(Ph<RTPPDN@    <@ 2 " 4 PXh]"$& B@  FIA-52 Tools(* B@ DEFINE DIALOG BOXFFIA-52 Tool Help B@,  ,**To CHANGE Case Info WITHOUT closing form** B@d; 21. Click Clear Case Info Button on FIA-52 Toolbar B@d;" 22. Click Change CaseInfo Button on FIA-52 Toolbar B@dR.  to bring up new pop-up screen. B@d;: +3. Enter new case information and click OK. B@d;H -The new information will fill in on the form. B@d \ **To ADD Child(ren) Row** B@d;h 0Click Add Children Row Button on FIA-52 Toolbar B@d | **To ADD Legal Status Row** B@d; 4Click Add Legal Status Row Button on FIA-52 Toolbar B@d  "**To ADD Social Work Contact Row** B@d; 4Click Add SocWk Contact Row Button on FIA-52 Toolbar B@d  **To ADD Child Information Row** B@d; 1Click Add Child Info Row Button on FIA-52 Toolbar B@d  **To Add Service Referal Row** B@d; 3Click Add Svc Referral Row Button on FIA-52 Toolbar B@d  5**To Add Column Headings for Service Referral Table** B@d; 1Click Add SvcRef Heading Button on FIA-52 Toolbar B@d  %**To Remove Entire Row from any table B@d;( /Click Remove Table Row Button on FIA-52 Toolbar B@d J B@d Z B@d j B@d^N B@. B@0]F !4!6.26GET USER INFO FROM INI FILE AND PUT IT INTO DIALOG BOX,DISPLAY DIALOG BOX AND RESPOND TO USER INPUT 2 !8%6'  OK BUTTONGet user info from INI file. Update other Form Fields on Form & Exit MacrokoAttribute VB_Name = "AddHeadDialog" Public Sub MAIN(), ".|DescriptionView i@nstruc&s for using FIA-# tons.ePProcData\Invok@e_Func\Template"ject. .QDim iRet WordB asic.Toolbars ColorButA:=1, LarDge0, T8ips"':="k52s", Show 'DEFINE DIALOG BOX 'Begin 582, 40= ' Help i fText 9, 1513, "**To CHANGE Case Info WITHOUT cloƨm**)52!1. C@k@earK |?W W34, G2Fhange7,lM6Er" to brup npop-q@eenPS>58 (3. EntTercSiSrDmaandTick OK7JSTheB wilHl finStoh@h9B}ADD Child(ren) Rowx10Jb< iC  0ekQ2 &Legal Status~3f9aZgf5j Soc@ k\@ontact6jE` We;18j 3*Y(vc/c?.5ddd!umnadCӪ!Tablez6hSvc` 8/hRemo$veair@+ow from any t29pi 2-dl\Tg33u4Mu6~OKH4R735@723&0GqEn dlgUserA"eAs Ob: Set =a?4CurValu8es.sy1'GET USER INFO FRO MIЌLE AND PuIT0 TO~ISPL AYhRESPO0 Qo`G C( ИIFf0-1 en 'OK BUTTON up#INIge UpdД oPgr Form F`ields}& Exit MacroP If q` ME(<<< <  `@|66EAdd heading row if Service Referral table expands to a second page. "TemplateProject.SvcRefHeading.MAIN8%P9K 7 "   (8RP2  2H ` p2   2  0 @2P   2   2  X h x2  2  ( 84H   4   ( 8Xp B@ B@ B@ B@nstruc060 pt0.2"$V  B@ B@svcrefh1 B@ B@ B@xsvcrefh2 B@ B@ B@ B@svcrefh3 B@ B@ B@ B@svcrefh4 B@ B@ B@ B@svcrefh5 B@ B@ B@ B@svcrefh6 B@ B@ B@ B@svcrefh7 B@ B@ B@ B@svcrefh8 B@ B@ B@svcrefh9 B@ B@ B@ B@ svcrefh10 B@ B@ B@ B@ svcrefh11 B@ B@ B@ BB@D  B!(  B!(Nl B@o`˲Attribute VB_Name = "SvcRefHeading" Public Sub MAIN(), ".|DescriptionAdd h row if Service erral table expands to a second page. }hProcDatatInvok@e_FunctTemplate"ject. .QWordBasic.FileSave ToolsUnprot"Document \SelRow @Insert num~s:=" $=C3?CMHh4?$6E5Ev?$|H6膽7"$|8?|9__!!e!1ߝCWW>pSm|.@c3rFp_.BoldpwwdToggltt?;vv{v @norese , Typpq2 E@ ID="{92796A43-45DE-470C-BDE9-069F7A426DA6}" Document=ThisDocument/&H00000000 Module=AddHeadDialog Module=NewMacros Module=PopUpPrompt2 Module=PopUpPrompt3 Module=SvcRefHeading Module=AddFamAssess Module=AutoSave Module=Module1 Name="TemplateProject" HelpContextID="0" VersionCompatible32="393222000" CMG="6567880CB860BC60BC60BC60BC" DPB="BDBF50F4F04DF14DF14D" GC="1517F85C08B509B5094A" [Host Extender Info] &H00000001={3832D640-CF90-11CF-8E43-00A0C911005A};VBE;&H00000000 [Workspace] ThisDocument=0, 0, 0, 0, C AddHeadDialog=132, 174, 771, 621, NewMacros=66, 66, 611, 506, PopUpPrompt2=165, 165, 758, 605, PopUpPrompt3=33, 33, 626, 473, SvcRefHeading=154, 203, 793, 650, C AddFamAssess=220, 220, 761, 667, AutoSave=176, 176, 717, 623, Z Module1=0, 0, 0, 0, C ThisDocumentThisDocumentAddHeadDialogAddHeadDialogNewMacrosNewMacrosPopUpPrompt2PopUpPrompt2PopUpPrompt3PopUpPrompt3SvcPROJECTwmeCCompObjkjRefHeadingSvcRefHeadingAddFamAssessAddFamAssessAutoSaveAutoSaveModule1Module1  FMicrosoft Word Document MSWordDocWord.Document.89q @ bjbj y$s,,ޡޡޡޡޡҥ*Y(lҥ x | @$$RvޡMMMޡޡ؏MMMMޡޡMMMM64wޡޡY;  pWM6>9;S06.vMv|;ҥҥޡޡޡޡvޡ; MMMMMMMMҥҥGMҥҥIf you need more than one family assessment click here. FORMTEXT      Does child have family participation in reunification and or treatment planning? Yes  FORMCHECKBOX  No  FORMCHECKBOX 1.Family Participation If the youth has an identified family participating in services, provide information on the participation in services. Include any relevant information on changes in the family since the last assessment.   MACROBUTTON [1] "Click Here and Type"  2.Family Assessment of Needs and Strengths Briefly outline the observations and other facts that led to each individual item scored as a need or strength on the Family Assessment of Needs and Strengths for either caretaker. If there is more than one household involved in planning for the child, score both households separately. 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 worker is unable to obtain information at the ISP, Record US for Unable to Score If there are significant discrepancies between facility scoring of any need item and the worker with primary family responsibility, it must be resolved through a conference with the family worker.   MACROBUTTON [1] "Click Here and Type"  Family Name FORMTEXT      Primary CaretakerSecondary CaretakerMost SeriousS1.Emotional Stability Behaviora. Exceptional coping skills +2b. Appropriate responses 0c. Some problems -3d. Ch      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~ronic depression, severely low esteem, emotional problems -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S1. EMOTIONAL STABILITY BEHAVIOR 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS2.Parenting Skillsa. Strong skills s +2b. Adequate skills 0c. Improvement needed -3d. Destructive/abusive parenting -5e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS3.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 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. 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS4.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS5.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS6.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS7.Communication/Interpersonal Skillsa. Appropriate skills 0b. Limited or ineffective skills -2c. Isolating/hostile/destructive -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS8.Housinga. Adequate housing 0b. Some housing problems, but correctable -2c. No housing, eviction notice -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S8. HOUSING A. Adequate housing  Family has adequate housing of sufficient size to meet their basic needs. B. Some housing problems, but correctable - Family has housing, but it does not meet the health/safety needs of the children due to such things as inadequate plumbing, heating, wiring, housekeeping, or size. C. No housing, eviction notice  Family has eviction notice, house has been condemned, is uninhabitable, or family has no housing.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS9.Intellectual Capacitya. Average or above functional intelligence 0b. Some impairment, difficulty making skills -2c. Severe limitation -4d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S9. INTELLECTUAL CAPACITY A. Average or above functional intelligence  Caretaker appears to have average or above average functional intelligence. B. Some impairment, difficulty in decision making skills  Caretaker has limited intellectual and/or cognitive functioning which impairs ability to make sound decisions or to integrate new skills being taught, or to think abstractly. 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).  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS10.Literacya. Literate 0b. Marginally literate -2c. Illiterate -3d. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS11.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS12.Employmenta. Employed +1b. No need 0c. Unemployed but looking -1d. Unemployed, not interested -2e. Unable to score US FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS13.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 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.  MACROBUTTON [1] "Click Here and Type"  Primary CaretakerSecondary CaretakerMost SeriousS14.Child Characteristicsa. 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 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.  MACROBUTTON [1] "Click Here and Type"  Based on this assessment, identify below the priority needs and strength of the family 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 Characteristics3.Family Strengths Provide information on any other strength for the family not identified in the needs and strengths assessment.  MACROBUTTON [1] "Click Here and Type"  Name:Date of Birth:Case Number: FORMTEXT       FORMTEXT       FORMTEXT      Child s Address if not FH:Date Entered Care: FORMTEXT       FORMTEXT      Current Placement Type:Date of Current Placement:Anticipated Next Placement Type:Date Anticipated Next Placement: FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMTEXT      Perm. Plan GoalMichigan Goal FORMDROPDOWN  FORMDROPDOWN  Sex: Race:Check if Ethnicity is Hispanic/Latino: FORMDROPDOWN  FORMDROPDOWN  FORMCHECKBOX  Name and Title:  FORMTEXT       Signature: Date:  Name:Relationship:Date of Birth: FORMTEXT       FORMTEXT       FORMTEXT      Parent s Current Address:Telephone: FORMTEXT       FORMTEXT      Sex:Race:Check if Ethnicity is Hispanic / Latino: FORMDROPDOWN  FORMDROPDOWN  FORMCHECKBOX  Parent/Caretaker Name:  FORMTEXT        Parent/Caretaker Signature:  Date:   FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       3.Family Assessment of Needs and Strengths If there are no parents for the child or if they are not involved in the planning for placement of the child, do not score any item. Briefly outline the observations and other facts that led to each individual item scored as a need or strength on the Family Assessment of Needs and Strengths for either caretaker. If there is more than one household involved in planning for the child, score both households separately. 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 worker is unable to obtain information at the ISP, Record US for Unable to Score If there are significant discrepancies between facility scoring of any need item and the worker with primary family responsibility, it must be resolved through a conference with the family worker Family 1Family 2 Primary Caretaker Secondary CaretakerMost Serious Primary Caretaker Secondary CaretakerMost SeriousS1.Emotional Stability Behaviora. Exceptional coping skills +2b. Appropriate responses 0c. Some problems -3d. Chronic depression, severely low esteem, emotional problems -5 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  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.  MACROBUTTON [1] "Click Here and Type"  S2.Parenting Skillsa. Strong skills +2b. Adequate skills 0c. Improvement needed -3d. Destructive/abusive parenting -5 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  S3.Substance Abusea. No evidence of problem 0b. Caretaker with some substance problem -2c. Caretaker with serious problem -3d. Problems resulting in chronic dysfunction -5 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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 some problem  Caretaker displays some substance abuse problem resulting in disruptive behavior, causing some discord in family, or is currently receiving treatment or attending support program. Based on available evidence, it appears that caretaker substance abuse creates some problems for the caretaker or the family. Consider as some problems the following: the impact on the family is not known, but staff have on two or more occasions observed indicators of intoxication such as slurred speech, glassy eyes, unsteady gait, odor of alcohol, drug paraphernalia; the caretaker has been arrested once in the past two years for alcohol or drug-related offenses or has refused breathalyzer testing or has had home raided for suspected drug involvement; 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 or inadequately supervised by caretaker because of substance abuse (i.e., caretaker physically absent due to use or passed out); staff have observed or received reliable reports that caretaker substance abuse results in conflict in family over use (e.g., arguments between spouses or between children and caretaker over use); 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. C. Caretaker with serious problem  Caretaker has serious substance abuse problems resulting in such things as loss of job, problems with the law, family dysfunction. Based on available evidence, it appears that caretaker 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 Syndrome; caretaker has ever been fired for substance abuse (and has not sought or benefited from treatment); caretaker has been arrested two or more times for alcohol or drug-related offenses; reliable reports of, or staff have observed, violence toward family members by caretaker while under the influence; reliable reports of daily intoxication; in-patient treatment or recommendation for same within past two years (and not in recovery); self-reported major problem; caretaker has been diagnosed as substance dependent; child or spouse reports observation of caretaker using drugs, or children have knowledge of whereabouts of drugs in household; multiple positive urine screens. 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 loss; multiple arrests that are related to the caretakers substance abuse; caretaker has had a serious problem with substance abuse, been in recovery, and recently has relapsed; caretaker has a serious medical problem(s) resulting from substance abuse; caretaker is dependent on a substance; there has been regular pre-natal exposure of children to substances - this includes exposure in more than one pregnancy, children diagnosed FAS or FAE, or children with a positive toxicology screen at birth.  MACROBUTTON [1] "Click Here and Type"  S4.Domestic Relationsa. Supportive Relationship +2b. Single caretaker not involved in domestic relationship 0c. Domestic discord, lack of cooperation -2d. Serious domestic discord/domestic violence -4 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S4. 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.  MACROBUTTON [1] "Click Here and Type"  S5.Social Support Systema. Strong support system +2b. Adequate support system 0c. Limited support system -2d. No support or destructive relationships -4 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S5. 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.  MACROBUTTON [1] "Click Here and Type"  S6.Communication/Interpersonal Skillsa. Appropriate skills 0b. Limited or ineffective skills -2c. Isolating/hostile/destructive -4 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S6. 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.  MACROBUTTON [1] "Click Here and Type"   Primary CaretakerSecondary CaretakerMost Serious Primary CaretakerSecondary CaretakerMost SeriousS7.Literacya. Literate 0b. Marginally literate -2c. Illiterate -3 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S7. 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.  MACROBUTTON [1] "Click Here and Type"  S8.Intellectual Capacitya. Average or above functional intelligence 0b. Some impairment, difficulty in decision making skills -2c. Severe limitation -4 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S8. INTELLECTUAL CAPACITY A. Average or above functional intelligence  Caretaker appears to have average or above average functional intelligence. B. Some impairment, difficulty in decision making skills  Caretaker has limited intellectual and/or cognitive functioning which impairs ability to make sound decisions or to integrate new skills being taught, or to think abstractly. 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). C. 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.  MACROBUTTON [1] "Click Here and Type"  S9.Employmenta. Employed +1b. No need 0c. Unemployed but looking -1d. Unemployed, not interested -2 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S9. 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.  MACROBUTTON [1] "Click Here and Type"  S10.Physical Health Issuesa. No problem 0b. Health problem or physical limitation that affects family -1c. Serious health problems or physical limitation that affects ability to Provide for or protect child -2 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S10. 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.  MACROBUTTON [1] "Click Here and Type"  S11.Resource Availability/Managementa. Strong money management skills +1b. Sufficient income to meet needs 0c. Income mismanagement -2d. Financial crisis -3 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN 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.  MACROBUTTON [1] "Click Here and Type"  S12.Housinga. Adequate housing 0b. Some housing problems, but correctable -2c. No housing, eviction notice -4 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S12. HOUSING A. Adequate housing  Family has adequate housing of sufficient size to meet their basic needs. B. Some housing problems, but correctable - Family has housing, but it does not meet the health/safety needs of the children due to such things as inadequate plumbing, heating, wiring, housekeeping, or size. C. No housing, eviction notice  Family has eviction notice, house has been condemned, is uninhabitable, or family has no housing.  MACROBUTTON [1] "Click Here and Type"  S13.Sexual Abusea. No evidence of problem 0b. Caretaker has failed to protect child(ren) from sexual abuse -4c. Caretaker has abused child(ren) sexually -5 FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN S13. 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.  MACROBUTTON [1] "Click Here and Type"  S14.Child CharacteristicsChild(ren)Child(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. 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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.  MACROBUTTON [1] "Click Here and Type"  Based on this assessment, identify below the priority needs and strength of the family below (indicate S code only). Address the priority items in the Treatment Plan and Service Agreement:Family 1Family 2PRIMARY NEEDSS1 Emotional Stability BehaviorS8 Intellectual Capacity1. FORMDROPDOWN  FORMDROPDOWN S2 Parenting SkillsS9 EmploymentS3 Substance AbuseS10 Physical Health issues2. FORMDROPDOWN  FORMDROPDOWN S4 Domestic RelationsS11 Resource Availability / MgmtS5 Social Support SystemS12 Housing3. FORMDROPDOWN  FORMDROPDOWN S6 Comm. / Interpersonal SkillsS13 Sexual AbuseS7 LiteracyS14 Child CharacteristicsPRIMARY STRENGTHSFamily 1Family 2S1 Emotional Stability BehaviorS8 Intellectual Capacity1. FORMDROPDOWN  FORMDROPDOWN S2 Parenting SkillsS9 EmploymentS3 Substance AbuseS10 Physical Health issues2. FORMDROPDOWN  FORMDROPDOWN S4 Domestic RelationsS11 Resource Availability / MgmtS5 Social Support SystemS12 Housing3. 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5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l)555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l)555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l)555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)55      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~5 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l)555 5I5A5N4avp<Df;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l)555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4az$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp<$$Ifv!vh555 5I5A5N#v#v#v #vI#vA#vN:V l555 5I5A5N4avp< Df;Select most serious score between two caretakers in family. 0-1-2-3US Df;Select most serious score between two caretakers in family. 0-1-2-3US Df;Select most serious score between two caretakers in family. 0-1-2-3US&$$Ifv!v h555 555555 #v#v#v #v#v#v#v#v#v :V l555 555555 / / / 4avL$$Ifz!vh5|)#v|):V l5|)4azL$$Ifz!vh5)#v):V l")5)4azL$$Ifz!vh5)#v):V l")5)4azDText4Enter household name.$$Ifz!vh5555T5 #v#v#v#vT#v :V l4 "),5555T5 4azf4$$Ifz!vh55555 #v#v#v#v#v :V l4")55555 4azf4JDf9Select first of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 / 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4JDf9Select first of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 / 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4JDf9Select first of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 / 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4JDf9Select first of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 / 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4JDf9Select first of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 / 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4JDf9Select first of top three priority needs for household 1. S1S2S3S4S5S6S7S8S9S10S11S12S13S14$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 / 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4$$Ifz!vh5 5~ 5h5555 #v #v~ #vh#v#v#v#v :V l4"),5 5~ 5h5555 4azf4R$$Ifz!vh5")#v"):V l4")5")4azf4$$Ifz!vh5f555$#vf#v#v#v$:V l4")5f555$4azf4L$$Ifz!vh5)#v):V l5)4az$$Ifz!vh5t5(5 #vt#v(#v :V l@)5t5(5 /  4azjDjDjD$$Ifz!vh5t5(5 #vt#v(#v :V l@)5t5(5 /  4azz$$Ifz!vh5!5:#v!#v::V l4@)5!5:/  4azf4jDjDt$$Ifz!vh5!5:#v!#v::V l@)5!5:/ 4az$$Ifz!vh5 555*#v #v#v#v*:V l4@)5 555*/  4azf4Df Foster HomeIndependent LivingRelative Residential Adoptive HomeOwn HomeOthervDText35Df  Residential Parental HomeLic/Unlic relativeLegal Guardian Adoptive HomeLic Unrelated Foster HomeIndependent LivingUnrelated CaregiverOtherjD$$Ifz!vh5 555*#v #v#v#v*:V l@)5 555*/ 4az$$Ifz!vh5m5#vm#v:V l4@)5m5/  4azf4p\Df ReunificationAdoption Guardianship!Permanent Placement with Relative*Placement in Another Planned Living ArrangDf Dropdown11  Emancipation by Age 19Permanent Placement w/relative Return HomeAdoption$Termination of Parental Rights/Adopt!Permanent Foster Family AgreementMaintain Own Placement Guardianship$$Ifz!vh5m5#vm#v:V l@)5m5/  4azp$$Ifz!vh5l55:#vl#v#v::V l4 @)5l55:/  4azf4Df Dropdown7 MFDf Dropdown1Select child's race. WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsian&Native Hawaiian/Other Pacific IslanderUnable to DeterminetDeCheck7$$Ifz!vh5l55:#vl#v#v::V l@)5l55:/ 4azDText12Enter Foster Care Worker's Name$$If!vh5 555#v #v#v#v:V l45 555/ 4f4$$If!vh5 555#v #v#v#v:V l45 555/ / 4f4$$Ifz!vh55 5#v#v #v:V l455 5/  4azf4jDjDjD$$Ifz!vh55 5#v#v #v:V l455 5/  4azf4v$$Ifz!vh5 5#v #v:V l45 5/  4azf4jDjDv$$Ifz!vh5 5#v #v:V l45 5/ 4azf4$$Ifz!vh555#v#v#v:V l4555/  4azf4Df Dropdown7 MFDf Dropdown1Select child's race. WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsian&Native Hawaiian/Other Pacific IslanderUnable to DetermineDeTerminationFromFoste&Check if child has been returned home.PromptAddParentRows$$Ifz!vh555#v#v#v:V l4555/ 4azf4DText15Enter Parent/Caretaker NamePopUpPrompt3.MAIN$$If!vh5D 5&55#vD #v&#v#v:V l45D 5&55/ 4f4$$If!vh5D 5&55#vD #v&#v#v:V l45D 5&55/ / 4f4vDText11Df C1C2C3C4C5C6C7C8C9S1S2S3S4S5S6S7S8S9S10S11S12S13S14Df ADDCDVEDFCFRHSILJTMDMHOTPSTHWPjDjDjDjDnDfD1 = Service Unavailable 2 = Continue Services 3 = Refused Services 1=Svs Unavlbl 2=Cont Svs 3=Refusd Svs4=New Df S=Satisfact U=UnsatisfjDl$$Ifl!v h5585B5|555t55 5 5#v#v8#vB#v|#v#vt#v#v #v 5:V l4:5585B5|55t55 5 5/ /  / / / / / 4alf4$$If!vh555*5N%#v#v#v*#vN%:V l4555*5N%4f4$$If!vh55555~ 55 #v#v#v#v#v~ #v#v :V l 55555~ 55 4$$If!vh55555~ 55 #v#v#v#v#v~ #v#v :V l 55555~ 55 4$$If!v h555555555 5 #v#v#v#v#v#v#v #v :V l 5555555 5 4j$$If!vh5 555v55v55v5 !5 5 5 5 5 #v #v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l 5 555v55v55v5 !5 5 5 5 5 4Ukd$$$Ifl8drlz "#u&'* vvv! 88884 laj$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l 5555v55v55v5 !5 5 5 5 5 4Ukd'$$Ifl8drlz "#u&'*vvv! 88884 laj$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l 5555v55v55v5 !5 5 5 5 5 4Ukd+$$Ifl8drlz "#u&'*vvv! 88884 laj$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l 5555v55v55v5 !5 5 5 5 5 4Ukdf/$$Ifl8drlz "#u&'*vvv! 88884 la Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US Df;Select most serious score between two caretakers in family. +20-3-5US$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l 5555v55v55v5 !5 5 5 5 5 / / / / / / 4Ukdq9$$Ifl8drlz "#u&'*vvv! 88884 laj$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l 5555v55v55v5 !5 5 5 5 5 4Ukd=$$Ifl8drlz "#u&'*vvv! 88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4PkdA$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4PkdiE$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd"I$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4PkdL$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4PkdP$$Ifl8drlz "#u&'*vvv!88884 laDf Dropdown2;Select most serious score between two caretakers in family. +20-3-5USDf Dropdown2;Select most serious score between two caretakers in family. +20-3-5USDf Dropdown2;Select most serious score between two caretakers in family. +20-3-5USDf Dropdown2;Select most serious score between two caretakers in family. +20-3-5USDf Dropdown2;Select most serious score between two caretakers in family. +20-3-5USDf Dropdown2;Select most serious score between two caretakers in family. +20-3-5US$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 / / / / / / 4Pkd[$$Ifl8drlz "#u&'*vvv!88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkds_$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd,c$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkdf$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkdj$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4PkdWn$$Ifl8drlz "#u&'*vvv!88884 la Df;Select most serious score between two caretakers in family. 0-2-3-5US Df;Select most serious score between two caretakers in family. 0-2-3-5US Df;Select most serious score between two caretakers in family. 0-2-3-5US Df;Select most serious score between two caretakers in family. 0-2-3-5US Df;Select most serious score between two caretakers in family. 0-2-3-5US Df;Select most serious score between two caretakers in family. 0-2-3-5US$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 / / / / / / 4PkdXx$$Ifl8drlz "#u&'*vvv!88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd|$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd<$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 la Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 / / / / / / 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd!$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkdڝ$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4PkdL$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 la Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US Df;Select most serious score between two caretakers in family. +20-2-4US$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 / / / / / / 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkdx$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd1$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 laDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4US$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 / / / / / / 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lac$$If!vh55 )#v#v ):V l455 )4f4$$If!v h555555555 #v#v#v#v#v#v#v#v :V l455555555 4f4e$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4Pkd$$Ifl8drlz "#u&'*vvv!88884 lae$$If!vh5555v55v55v5 !5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v !#v #v #v #v #v :V l5555v55v55v5 !5 5 5 5 5 4PkdU$$Ifl8drlz "#u&'*vvv!88884 laDf;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3USDf;Select most serious score between two caretakers in family. 0-2-3US$$If!vh5555v55v55v5 5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v #v #v #v #v #v :V l5555v55v55v5 5 5 5 5 5 / / / / / / 4Pkd2$$Ifl8drlz"#u&'*vvv88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 5 5 5 5 5 #v#v#v#vv#v#vv#v#vv#v #v #v #v #v #v :V l5555v55v55v5 5 5 5 5 5 4Pkd$$Ifl8drlz"#u&'*vvv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd]$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 laDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4USDf;Select most serious score between two caretakers in family. 0-2-4US$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 / / / / / / 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4PkdI $$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 la Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US Df;Select most serious score between two caretakers in family. +10-1-2US$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 / / / / / / 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkdu$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd."$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd%$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd)$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4PkdY-$$Ifl8drlz"6$&'*vvvhv88884 laDf;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2USDf;Select most serious score between two caretakers in family. 0-1-2US$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 / / / / / / 4Pkd67$$Ifl8drlz"6$&'*vvvhv88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd;$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkda?$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4PkdC$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4PkdF$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4PkdJ$$Ifl8drlz"6$&'*vvvhv8888      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxy{|}~4 la Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US Df;Select most serious score between two caretakers in family. +10-2-3US$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 / / / / / / 4PkdT$$Ifl8drlz"6$&'*vvvhv88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4PkdX$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd\$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkdq`$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd*d$$Ifl8drlz"6$&'*vvvhv88884 laDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5US$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 / / / / / / 4Pkdn$$Ifl8drlz"6$&'*vvvhv88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkdyr$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd2v$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkdy$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd}$$Ifl8drlz"6$&'*vvvhv88884 laDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5USDf;Select most serious score between two caretakers in family. 0-4-5US$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 / / / / / / 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 la9$$If!v h55555v55v55 85 v5 5 #v#v#v#v#vv#v#vv#v#v 8#v v#v #v :V l55555v55v55 85 v5 5 4kd$$Ifl  drlz6$&'*vv8v00004 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd_$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 lae$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkdѡ$$Ifl8drlz"6$&'*vvvhv88884 laDf2Select response that best reflects this household. 0-1-2-3USDf2Select response that best reflects this household. 0-1-2-3US$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 / / 4Pkd~$$Ifl8drlz"6$&'*vvvhv88884 lac$$If!vh55 )#v#v ):V l455 )4f4e$$If!vh5555v55v55v5 5 5 h5 v5 5 #v#v#v#vv#v#vv#v#vv#v #v #v h#v v#v #v :V l5555v55v55v5 5 5 h5 v5 5 4Pkd$$Ifl8drlz"6$&'*vvvhv88884 laG$$If!vh5*#v*:V l5*4$$If!vh5555~ 55 #v#v#v#v~ #v#v :V l5555~ 55 4O$$If!v h555v55v55v55 5 h5 v5 5 #v#v#vv#v#vv#v#vv#v#v #v h#v v#v #v :V l555v55v55v55 5 h5 v5 5 4*kdq$$Ifl" drlz"6$&'*vvvhv44444 laHDf Dropdown1/Select each families' top three priority needs. S1S2S3S4S5S6S7S8S9S10S11S12S13S14HDf Dropdown1/Select each families' top three priority needs. S1S2S3S4S5S6S7S8S9S10S11S12S13S14$$If!vh5 5 5i55v55v55 v5 5 5 h5 v5 5#v #v #vi#v#vv#v#vv#v#v v#v #v #v h#v v#v #v:V l5 5 5i55v55v55 v5 5 5 h5 v5 5/ / 4vkd~$$IflN# drlz"6$&'*  ivvvhv<<<<4 la{$$If!vh5 5 5i55v55v55 v5 5 5 h5 v5 5#v #v #vi#v#vv#v#vv#v#v v#v #v #v h#v v#v #v:V l5 5 5i55v55v55 v5 5 5 h5 v5 54vkd$$IflN# drlz"6$&'*  ivvvhv<<<<4 laHDf Dropdown1/Select each families' top three priority needs. S1S2S3S4S5S6S7S8S9S10S11S12S13S14HDf Dropdown1/Select each families' top three priority needs. S1S2S3S4S5S6S7S8S9S10S11S12S13S14$$If!vh5 5 5i55v55v55 v5 5 5 h5 v5 5#v #v #vi#v#vv#v#vv#v#v v#v #v #v h#v v#v #v:V l5 5 5i55v55v55 v5 5 5 h5 v5 5/ / 4vkd$