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June 2010

37.

Is there a “CCFA (Comprehensive Child & Family Assessment)” or “First Placement-Best Placement”

recommendation in the file?

Yes

No

If yes, date of most recent:

_____ /_____ /_____

I f y e s , r e c o m m e n d e d p l a c e m e n t t y p e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

38.

If the child has been in foster care 15 of the most recent 22 months, has the agency filed or joined a petition

t o t e r m i n a t e p a r e n t a l r i g h t s , o r d o c u m e n t e d c o m p e l l i n g r e a s o n s w h y T P R i s n o t i n t h e b e s t i n t e r e s t o f t h e c h i l d ? N/A - Not in foster care 15 of last 22 months Yes No

39. Yes

Has the court terminated parental rights (TPR) on the child’s mother?

No

If yes, date:

_____ /_____ /_____

40. Yes

Has the court terminated parental rights (TPR) on the child’s father?

No

If yes, date:

_____ /_____ /_____

41.

Is there an Affidavit to Release Child for Adoption or other documentation of parent/s relinquishing cus-

tody? Yes No

If yes, date:

_____ /_____ /_____

DFCS Care

42.

Check all reasons for DFCS involvement, then circle the primary reason:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Physical abuse Sexual abuse Abandonment Neglect Parent substance abuse Parent mental/physical health Parent incarceration Parent death

_____ _____ _____ _____ _____ _____ _____

Parent/caretaker unable to cope Violence in home Inadequate housing Child’s behavior Child’s disability Child’s mental/physical health Other: ____________________________

43

.

Number of times this child been removed from their home by DFCS?

_____________

44.

Date of first DFCS removal _____ /_____ /_____

45. Yes

Has this child ever been labeled a “runaway”?

No

If yes, check if any of the following occurred:

_____ _____

Runaway report made Warrant filed

_____ _____

Report filed with the Natl Center for M&E Children Child was absent for more than a day

46. _____ _____ _____ _____ _____ _____

Foster Family

_____

Foster Relative

_____

Group Home

_____

Institution

_____

Pre-adoptive home

_____

Current placement:

Other

___________________________

Residential Therapeutic Treatment Runaway Juvenile justice placement Supervised independent living Trial home visit

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