Caregiver's Assessment of Child

              Caregiver's Assessment of Child
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 1 of 15
General Information
Date completed
Caregiver name
Child's first name Last name Child's date of birth
Foster parent
Relative
Other, specify:
How long has the child been in your home or this placement?
Less than 6 months
Less than one year
1 to 2 years
3 to 4 years
5 to 7 years
8 to 12 years
13 or more years
Information Regarding the Child
Describe the child's physical appearance and provide a current picture.
Height Weight Hair color Eye color
Unusual features or birthmarks
List the child's favorite:
Foods
Music
Activities or Caregiver's Assessment of Child
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 1 of 15
General Information
Date completed
Caregiver name
Child's first name Last name Child's date of birth
Foster parent
Relative
Other, specify:
How long has the child been in your home or this placement?
Less than 6 months
Less than one year
1 to 2 years
3 to 4 years
5 to 7 years
8 to 12 years
13 or more years
Information Regarding the Child
Describe the child's physical appearance and provide a current picture.
Height Weight Hair color Eye color
Unusual features or birthmarks
List the child's favorite:
Foods
Music
Activities or sports
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 2 of 15
Hobbies
Time of day
People
Possession, toy, or thing
Describe:
What makes the child happy?
What things frighten the child?
What makes the child sad?
What makes the child angry?
Interesting facts about child:
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 3 of 15
Check the boxes that best describe the child's personal characteristics.
Active
Aggressive
Awkward
Calm
Clingy
Emotional
Fearful
Flexible
Friendly/social
Fun/playful
Isolated
Kind
Manipulative/controlling
Moody
Self-confident
Serious
Shy
Sickly
Nervous/anxious Stubborn
Compassionate
Compliant
Curious
Disobedient
Easy going
Happy
Hardworking
Insecure
Irresponsible
Irritable
Outgoing
Perfectionist
Quiet
Sad
Self-centered
Temperamental
Unhappy
Violent
Worrier
Other characteristics:
Child's Relationships with Adults and Others in the Home
Rate the child's ability to relate to caregivers.
Primary caregiver: Male Female Secondary caregiver: Male Female
Very good
Good
Fair
Poor
Very good
Good
Fair
Poor
What do you like most about the child?
What are the most difficult things about living with the child?
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 4 of 15
How does the child relate to authority figures, such as teachers and therapists?
Very good Good Fair Poor
Other - describe:
Who are the significant adults in the child's life?
Birth mother
Maternal grandparent(s)
Teacher
Stepmother
Older sibling(s)
Birth father
Stepfather
Paternal grandparent(s)
Aunt(s) and/or uncle(s)
Cousin(s)
Foster parent(s)
Institutional caregiver(s)
School mentor
Church member
Neighbor
Adoptive parent(s)
Respite provider
Coach
Scout leader
Community mentor
Babysitter
With whom does the child have the closest relationship?
How have you incorporated this child into your family?
Other:
Allowance
Chores
Community sports
Cultural activities
Family expectations
Family gatherings
Family pictures Volunteerism
Holiday traditions
Music
Religious activities
Rules
Tribal activities
Vacations
What is the quality of the child's interaction with persons living in the home or residential setting?
Very good Good Fair Poor
How does the child react to other children being placed or leaving the foster home or residential
setting? Very good Good Fair Poor
Explain:
How does the child behave with peers? Very good Good Fair Poor
Child's Relationship with Peers
Describe the child's negative behaviors related to peer interaction.
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 5 of 15
Does the child relate better to children who are: Older Younger Same age
Does the child display a significant difference when relating to males or females? Yes No
If yes, explain:
Does the child relate better in: Large groups Small groups One–on–one
Does the child make friends: Easily With difficulty Not at all
Child's Culture
Does the child have a religious preference? Yes No Not applicable
If yes, what?
Does the child attend church? Yes No Not applicable
How often? Where?
Has the child been baptized? Yes No Not applicable Unknown
What language(s) does the child speak or understand?
Does the child practice or observe any of these cultural traditions or practices?
Holidays Yes No
Explanation of activity:
Beliefs Yes No
Explanation of activity:
Customs Yes No
Explanation of activity:
Habits Yes No
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 6 of 15
Explanation of activity:
Events Yes No
Explanation of activity:
Celebrations Yes No
Explanation of activity:
Spoken or unspoken rules Yes No
Explanation of activity:
Other Yes No
Explanation of activity:
Has the child expressed an interest to learn more about his or her culture? Yes No
In what ways have you helped the child explore the child's cultural interests?
Child's Birth Family
What are the child's stated feelings about his or her birth family?
What is the child's understanding about why he or she was removed from the home and why
parental rights were terminated?
Does the child maintain connections with the birth family? Yes No
If yes, with whom and how often?
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 7 of 15
Does the child have pictures of:
Father
Maternal grandparents
Aunts and/or uncles
Mother
Paternal grandparents
Sibling(s)
Is the child interested in locating his or her birth parents now or in the future?
Yes - who?
No - why?
Not applicable - explain:
Unsure
How many siblings does the child have?
Does the child visit with siblings? Yes No Unsure Not applicable
If yes, list siblings with whom the child visits.
If yes, how often do the child and sibling(s) visit?
If no, explain why the sibling(s) do not visit.
Does the child maintain connections with significant non-family individuals?
Yes - who?
No - why?
Not applicable - explain:
Unsure
How often?
How have you helped the child maintain significant relative or kin connections?
Does the child have a Life book? Yes No
Is the child involved in community or social activities such as girl or boy scouts, sports, or dance?
Yes No Not applicable
Child's Community
If yes, what?
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 8 of 15
Are there any other special relationships the child has in the community, such as church members or
teachers? Yes No Not applicable
If yes, who?
Child's Educational History
List the school the child attended while in your home or placement.
Name of school Grade Teacher
If applicable: mark the child's strengths or weakness associated with school.
Reading Strength Weakness
Math Strength Weakness
Spelling Strength Weakness
Other: Strength Weakness
Other: Strength Weakness
Other: Strength Weakness
Following instructions Strength Weakness
Completing homework assignments Strength Weakness
Paying attention in class Strength Weakness
Organizational skills Strength Weakness
Getting along with peers Strength Weakness
Respecting authority Strength Weakness
Does the child need help completing homework and assignments? Yes No
What are the child's most recent report card grades?
Is the child in special education? Yes No Not applicable
Has the child completed Individualized Educational Planning Consultation (IEPC) testing:
Yes No
Most recent testing date:
Testing location:
Do you have a copy of the most recent Individual Education Plan (IEP)? Yes No
What are the child's future educational needs?
What do caregivers for this child need to know about the child's educational needs?
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 9 of 15
Child's Daily Routine
How does the child care for possessions? Very good Good Fair Poor
How are the child's personal hygiene habits? Very good Good Fair Poor
Explain:
The child is capable of completing: bathing brushing teeth combing hair dressing self
Does the child's daily routine need to be: structured regimented flexible
Describe the child's eating habits?
Is the child allergic to any foods? Yes No
If yes, explain:
Is this child a morning person? Yes No
Shares a room with Older kids Younger kids or Has own room
What is the child's current sleeping arrangement?
What is the child's bedtime routine?
What suggestions do you have for the child's future caregivers regarding the child's daily routine?
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 10 of 15
Child's Sexual Development
Does the child display:
Age inappropriate knowledge of sex
Aggression toward others and pets
Bed-wetting:
Cruelty to animals
Excessive masturbation
Fear of certain places or locations
Fear of the opposite sex
How often?
Feces smearing
Fire-setting
Frequent questions regarding sex
Nightmares
Promiscuous behavior
Self-mutilation
Sexual play with others, toys or animals
Has the child exhibited sexual behavior beyond normal curiosity? Yes No
If yes, explain:
Is there a current pattern of sexual acting-out? Yes No
If yes, explain:
Does the child have any sexual identity issues? Yes No
If yes, explain:
Has the child expressed a sexual orientation toward a specific gender? Yes No
If yes, explain:
Child's Developmental and Emotional Functioning
Check each behavior the child displays.
Destructive to self, others, property
If checked, explain:
Difficulty forming attachments
Difficulty knowing right from wrong
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 11 of 15
Extreme control battles
Extreme mood swings
Hoarding or gorging food
Hyperactive, beyond age appropriate level
Inappropriately demanding
Lack of conscience or remorse
Lack of eye contact with parents
Lack of impulse control
Learning delays
Lies about the obvious
Manipulative
Poor peer relationships
Resists parental affection - age appropriate
Stealing
Family therapy
Group therapy
Individual therapy
In-home behavioral intervention, including:
In-patient treatment
What has been done to address these behaviors?
Medication
Modified school day
Not applicable
Is the child currently in therapy? Yes No
If yes, list:
When therapy began?
Therapist name Agency name
How often the child attends?
What issues are being addressed?
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 12 of 15
List each medication the child takes to control behavior.
Medication name Dosage How often Reason Prescribing doctor
What is the most effective discipline to effect a positive change in the child's behavior?
Consistently use reasonable consequences
Grounding
Ignore the child's misbehavior
Let child decide punishment
Make rules and consequences clear in advance
Natural consequences
Raising your voice
Rational discussion
Send child to room
Show disappointment
Take away privileges
Use of time out
Other
Have you ever seen the child out of control? Yes No
If yes, explain:
Describe the circumstance that initiates the child's out-of-control behavior?
Has the child ever physically attacked you or anyone else? Yes No Unsure
If yes, explain:
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 13 of 15
How does this child behave with animals?
Loving
Accepting
Afraid
Harmful
Indifferent
If harmful, explain:
Child shows affection: Openly Cautiously Does not
How does the child show affection?
Words
Acts of service
Hugs and kisses
Making or giving gifts
Quality time
Other
What is the child's level of cooperation and attention span?
Good Fair Manageable Poor
Child's Medical Needs
Does the child have any medical needs that require follow-up, such as asthma, diabetes, or cerebral
palsy? Yes No Unsure
If yes, explain:
Yes No Unsure
Does the child have any dental needs that require follow-up, such as orthodontic, cavities, or gum
disease?
If yes, explain:
Does the child need corrective lenses? Yes No Unsure
If yes, explain:
Does the child have any allergies? Yes No Unsure
If yes, explain:
List the medications the child is taking for on-going medical needs.
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 14 of 15
Medication name Dosage How often Reason Prescribing doctor
Does the child require any special equipment? Yes No Unsure
If yes, explain:
Child's Attitude Toward and Readiness for Adoptive Placement
Explain the child's understanding of the concept or definition of adoption.
If anyone talked to the child about adoption, explain who did and what was discussed.
What are the child's stated feelings about being placed for adoption?
If the child identified any preferences and concerns about adoption, explain.
Describe living situations and placements the child identified that would make the child more
comfortable or uncomfortable.
Placement Provider Expertise
Detail information regarding the child and child's family that future caregivers need to know.
What do you wish you would have known about this child when the child was first placed in your
home?
Form 04AN026E (DCFS-90) v.3 11/08/2012 Page 15 of 15
Explain what the child needs from a caregiver, such as a certain amount of time, types of affection
and attention, types of discipline, need for closeness or distance, or bedtime routine.
Other comments: