WV SAFETY ASSESSMENT AND MANAGEMENT SYSTEM Family Functioning Assessment

FAMILY ASSESSMENT AREAS AND IMPENDING DANGERS

ASSESSMENT AREA ONE: MALTREATMENT 1. Maltreatment: What is the extent of the maltreatment?

ASSESSMENT AREA TWO: NATURE OF MALTREATMENT 2. Nature: What surrounding circumstances accompany the alleged maltreatment? Documentation must include the caregivers explanation of circumstances even if the finding is no maltreatment.

Related Impending Danger Threats: Based on case information specific to the Maltreatment and Nature Assessment Areas, indicate Yes Impending Danger exists or No Impending Danger does not exist. Yes ____ No____ Living arrangements seriously endanger a childs physical health. Yes ____ No ____ Family does not have resources to meet basic needs. Yes ____ No ____ One or both caregivers intend(ed) to hurt child.

ASSESSMENT AREAS THREE AND FOUR: PARENTING 3. Parenting Discipline: What are the disciplinary approaches used by the caregivers, and under what circumstances? Caregiver 1:

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Caregiver 2:

4. Parenting General: What are the overall, typical, parenting practices used by the caregivers? (Do not include discipline.) Caregiver 1:

Caregiver 2:

Impending Danger Threats: Based on case information specific to the Parenting Assessment Areas, indicate Yes Impending Danger exists or No, Impending Danger does not exist. Yes ____ No ____ Child is perceived in extremely negative terms by one or both caregivers. Yes ____ No ____ The caregiver is unwilling or unable to perform parental duties and responsibilities, which could result in serious harm to the child. Yes ____ No ____ One or both caregivers fear they will maltreat child and/or request placement. Yes ____ No ____One or both caregivers lack parenting knowledge, skills, or motivation which affects child safety. ASSESSMENT AREA FIVE: ADULT FUNCTIONING 5. Adult Functioning: How does the adult caregiver function with respect to daily life management and general adaptation? Always include mental health; physical health; substance use; social and domestic relations. Caregiver 1:

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Caregiver 2:

*additional caregivers as needed 5-a Adult Functioning - Other adults/significant others in the home Other adult and relationship to child, if any:

Impending Danger Threats: Based on case information specific to the Adult Functioning Assessment Area, indicate Yes Impending Danger exists or No, Impending Danger does not exist. Yes ____ No ____ The caregivers drug and/or alcohol use is pervasive and threatens child safety. Yes ____ No ____ One or both caregivers are violent; this includes Domestic Violence and General Violence. Yes ____ No ____ One or both caregivers cannot control behavior.

ASSESSMENT AREA SIX - CHILD FUNCTIONING 6. Child Functioning: How does the child function on a daily basis? Include behaviors, feelings, intellect, physical capacity and temperament. Always include mental health; physical health; education needs; peer relations, social and personal development. Child 1

Child 2

Child 3

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*Add additional children as needed

Impending Danger Threats: Based on case information specific to the Child Functioning Area, indicate Yes Impending Danger exists or No, Impending Danger does not exist. Yes ____ No ____ Child has exceptional needs which the caregivers cannot or will not meet.

SECTION C: CONCLUSION (SAFETY DECISION)

The Child(ren) is/are safe (because) no impending dangers were identified.

Based on specific case information, explain how the enhanced caregiver protective capacities ensure child safety below.

The Child(ren) is/are unsafe (because) one or more impending danger threats were identified. The case must be opened for Ongoing CPS. Proceed to SECTION D: Safety Analysis and Planning. Based on specific case information, explain below how the diminished caregiver protective capacities affect child safety.

Decision to Provide Ongoing CPS and Transfer Summary Indicate the reason(s) below why the family is or is not being opened for ongoing CPS.

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A. _______ Child(ren) in the household were identified as UNSAFE. The case will be opened for Ongoing CPS. Proceed to SECTION D: Safety Analysis and Planning in order to develop and implement a sufficient safety plan. There were no children in the household identified as unsafe or maltreated. The case will not be opened for Ongoing CPS. The family will be referred for community resources and services as applicable. There were no children in the household identified as unsafe, however maltreatment was substantiated based on WV Code 49-1-3. WV Code 49-6D-2 indicates that a plan be implemented where every abused or neglected child in the state is provided an environment free from abuse or neglect. For this reason the case will be open for Ongoing CPS Services.

B. _______

C. _______

Justify the decision to open the case for Ongoing CPS or close the case following the Family Functioning Assessment:

SECTION D: SAFETY ANALYSIS AND PLANNING

Complete safety analysis and planning on all cases where children are identified as unsafe and in need of protection. This establishes reasonable efforts and rationale for the type of safety plan developed (inhome safety plan or out of home safety plan-placement). You must staff the case immediately with a supervisor to determine the next steps. Justify any case specific information for any/all no and yes determinations: Justification for the use of an In-Home Safety Plan or the need for Out of Home Placement (safety Plan): ____YES _ _NO The caregivers are willing for an in-home safety plan to be developed and implemented and have demonstrated that they will cooperate with all identified safety service providers. The home environment is calm and consistent enough for an in-home safety plan to be implemented and for safety service providers to be in the home safety. Safety services are available at a sufficient level and to the degree necessary in order to manage the way in which impending danger is manifested in the home. An in-home safety plan and the use of in-home safety services can sufficiently manage impending danger without the results of scheduled professional evaluations.

____YES _ _NO

____YES _ _NO

____YES _ _NO

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____YES _ _NO The caregivers have a residence in which to implement an in-home safety plan. (this could include shelter, friend/relatives home, etc)

If the answer is NO to any of the safety analysis questions then the determination is that an in-home safety plan CANNOT sufficiently control impending danger and assure child safety. Any NO response indicates the need to pursue the use of an out of home safety plan (placement) and/or the determination that child(ren) must remain in placement. If the answers to the questions are yes, proceed with the development of an in-home safety plan.

Out of policy action- If the safety analysis confirmed the need for an out of home safety plan (placement) but an in-home safety plan was implemented because efforts to petition for custody were denied by the judge or prosecuting attorney, document all efforts made including results of the dispute resolution contained in West Virginia Code Chapter 49, Article 6, Section 10a (49-6-10a) below.

SECTION E: APPROVAL OF FAMILY FUNCTIONING ASSESSMENT

The Family Functioning Assessment policies were followed: YES - (Interview process, identifying dates, sources of information and other important case information that would not be included on this summary should be documented below). NO - (If timeframes are not met for the initial contact or the completion of the family functioning assessment, document the rationale and/or justification below. If the interview protocol was not or could not be followed, or an interview is waived; document rationale and justification below).

Does the documentation support the finding of maltreatment or lack of maltreatment? Yes/No Does the documentation support the Family Functioning Assessment Conclusion? Yes/No Is the safety plan appropriate given the identified impending dangers, protective capacities and child vulnerabilities? Yes/No/NA Are necessary parties to the safety plan in agreement and capable of assuring the childs safety? Yes/No/NA
Supervisory Approval of the Maltreatment Finding, Safety Conclusion, and Safety Plans if appropriate: _________________________________________ Signature _____________________________ Date

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