kinship caregiver home assessment

Texas Department of Family and Protective Services

Form 6588 April 2019

CK Kinship Guide Updated 2.5.2020 of 22

Kinship Caregiver Home Assessment

Case Name: (Name of Person With the CPS Case)

Case ID Number: Family Name: Name of Couple or Person Being Studied

Address City, State Zip

County

CONTRACTOR’S INFORMATION

Assessment Provided by:

Phone:

Provider Email:

Subcontractor: Phone:

Subcontractor Email: CPS CASEWORKER, SUPERVISOR, PROGRAM DIRECTOR

Caseworker’s Name: Supervisor’s Name: Program Director’s Name: Unit #: Region #: For all cases please use the worker/supervisor listed on the 2700. *For Region 3 ICPC cases, complete the above section with the following information: Caseworker’s Name: ICPC staff Supervisor’s Name: Catherine Irons Program Director’s Name: ICPC staff Unit #: G6 Region #: 3 General Information about the case history and the caregiver under consideration: Include the reasons the child was removed – this should be a brief summary of the Affidavit of Removal. Please state where you received the information and the date of the document. [i.e. “The following information was obtained from the Affidavit of Removal dated 01/01/2013.”]

If applicable, please state “No Affidavit was provided. This is a base petition.” If no affidavit is provided, please call or email the CPS worker to request one or to inquire about the reason for removal. If not received, document attempt to obtain information. Give a brief explanation about the relationship of children to kinship caregiver. If the family is fictive kin (i.e., not a related familial member; cousin, aunt, uncle, etc.) give a brief explanation of the relationship or how the family has come to know the children/biological family.

General Information Home Phone Number: Work Phone Number(s): Cell Phone Number(s):




Directions to home: Please include a starting point for your directions either a city or CPS office location from the referring agency

Identity of All household members All members living in the home, age 3 and over must be interviewed Face-to-Face in the home. If there is more than one caregiver, create a chart for each additional caregiver. To create an extra chart, scroll over the table/chart, and you will see a box in the top left corner with four arrows. Right click on the box, select copy. Bellow the chart, press enter, and simply paste the next chart. You can repeat this again if needed, and will do the same for all table/charts required for the household members throughout the home study. Make sure there is space between the charts before copy/pasting. Caregiver Information This section applies to the primary caregiver and any other adult who may provide care and/or supervision to the children. This may include, but is not limited to, basic needs, supervision, discipline, and decision-making. All members living in the home, age 3 and over must be interviewed Face-to-Face in the home. If there is more than one caregiver, create a chart for each additional caregiver. All cohabitating couples, regardless of legal marital status, need to be addressed as co-caregivers throughout the report.

Name:

Relationship to Child:

Gender:

Age/DOB:

Ethnicity: List race/ethnicity; ex: White/Hispanic, Black/Non-Hispanic; Caucasian and African-American are acceptable; please use the family’s preference

Language:

Religion:

Marital Status:

Citizenship:

Place of Birth:

Highest Level of Education:

Height/Weight

Hair Color/Eye Color:

Branch of Military:

Dates of Service:

Discharge:

Name:





Gender:

Age/DOB:

Ethnicity:

Language:

Religion:

Marital Status:

Citizenship:

Place of Birth:


Height/Weight


Branch of Military:

Dates of Service:

Discharge:

Child Household Members: If the subject child(ren) is already residing in the home, please include here.

Name:

Relationship to Kin Caregiver:


Time Residing in Home:

Gender:

Age/DOB:

Ethnicity:

Language:

Religion:

Citizenship:

Place of Birth:


Height/Weight





Name:




Gender:

Age/DOB:

Ethnicity:

Language:

Religion:

Citizenship:

Place of Birth:


Height/Weight


Name:




Gender:

Age/DOB:

Ethnicity:

Language:

Religion:

Citizenship:

Place of Birth:


Height/Weight


Name:







Gender:

Age/DOB:

Ethnicity:

Language:

Religion:

Citizenship:

Place of Birth:


Height/Weight


Additional Adult Household Members: This includes any household member over the age of 18, even if the person is a child of the caregiver and is still in high school.

Name:


Gender:

Age/DOB:

Ethnicity:

Language:

Religion:

Marital Status:

Citizenship:

Place of Birth:


Height/Weight


Branch of Military:

Dates of Service:

Discharge:




Identify children to be placed: Name:


Gender:

DOB:

Age:

Location of Current Placement:

Name:


Gender:

DOB:

Age:


Name:


Gender:

DOB:

Age:


Name:


Gender:

DOB:

Age:


School Information: Gather all school information regardless of age of child(ren).




School District Elementary School Middle School High School

Summary of contacts All household members (including part-time household members) age 3+ must be interviewed face to face. Please include in your contact regarding home visit/face to face interview with the caregiver that a Kinship Manual and survey were left with the family. *document the survey was left with the family. *document the Release of Info was signed; a Kinship Manual was left with the family; and one of the following: Kinship Profile Questionnaire was included in the referral or Kinship Profile Questionnaire was provided and completed by caregiver(s) (if this is the case then include in your submission) or Kinship Profile Questionnaire was provided to the caregiver(s) Do NOT leave Kinship Manual for ICPC families.

Date Location of Contact Person Contacted Type of Contact

Safety

Kinship Caregiver's understanding of why child(ren) was removed from the home: Explain the kinship caregiver's understanding of why the child(ren) was removed from the home. Assess if the kinship caregiver clearly describes the allegations of abuse and/or neglect and if they believe the abuse and/or neglect occurred.

• Assess if the kinship caregiver needs additional information about the abuse and/or neglect or if there is denial about the safety threats.

• Assess if the kinship caregiver understands the impact of the perpetrator’s behavior on the child(ren).

• Assess if the kinship caregiver believes there is a need to protect the child(ren) from the perpetrator.

• Make a statement that the caregiver appeared to understand the allegations or not, if they appeared protective or stated they would be protective. When assessing their understanding of the impact on the child, please indicate whether the caregiver recognizes how the current situation could/would impact the child.




Kinship Caregiver's plan should a child or youth’s behavior present a risk to themselves or others or significantly impairs daily functioning to ensure the child/youth and caregivers have the supports needed to prevent disruption of placement and promote a safe and therapeutic environment. High risk behaviors will be documented at the bottom of page 1 of form 6581 provided in referral documents. If there are no high-risk behaviors, make the following statement: “According to referral documents, the child(ren) do not have any high risk behaviors.” Describe the child/youth's high-risk behavior which may include but is not limited to sexual aggression, social isolation, bullying, revenge-seeking behaviors, lying, stealing, willful destruction of property, blaming others, impulsivity, actively defying or refusing to comply with rules, self-harming, drug/alcohol use, being cruel to animals, and playing with fire. Describe the caregivers plan to ensure safety in the home. Discussion should include plans regarding:

• Supervision around other children

• Resources available in the community

• Respite Care

• Safety Plan

• Information about important “warning signs” and the steps needed to get help

• Crises Intervention plan

Kinship Caregiver's feelings and attitudes toward the child(ren)'s parent(s) and other family members: Describe and address the kinship caregiver’s feelings and attitudes toward the child(ren)’s parent(s) and other family members. Ensure you address both parents of each child, siblings, other family members. Kinship caregiver's initial reasons for wanting the child(ren) placed in the home: Explain the kinship caregiver’s initial reasons for wanting the child(ren) placed in the home. Please be specific, do they want them there because they think they are going to get money, because they love them and they are family (what if they’ve only met the child once, or never), why would a family member want a child placed with them that they’ve never met, etc. Try to get as much out of the caregiver here as possible, we are talking about placing a child and the safety of that child. Kinship caregiver's feelings and attitudes about the potential placement of a related child in their home: Describe the kinship caregiver’s feelings and attitudes about the potential for placing a related child in the relative's home. How will this affect their family, their relationships with their family members, be specific about their feelings and attitudes, they said they were excited, they said they were nervous, etc. Kinship caregiver's future desires with respect to the placement: (For ICPC studies that are foster studies on a kinship caregiver, include the following statement – This home assessment is being conducted to determine the safety of the placement for [insert the name of the child(ren) to be placed] and to determine if [insert the kinship caregiver’s name(s)] is appropriate to refer to the foster and adoptive home development program for verification and/or approval). Check the 2700 to determine if this is a foster ICPC study.

For non-ICPC studies and non-foster ICPC studies, what do they want to happen with the placement? Are they willing to have a long-term placement, adoption, etc., or would they prefer the placement only be short term because they can’t afford long term? Try to be as specific as possible. This will be discussed in more detail later in the home study.




Kinship Caregiver's history of alcohol and drug use or Present Use Describe the kinship caregiver’s history or current use of drug or alcohol, if any: Create a new paragraph for each household member addressing all required content in this section for each person, if applicable. Discuss the kinship caregiver's statements about his/her or current use or history of drug or alcohol use if any. Be specific with history and current use of alcohol; include if they have ever consumed alcohol. Do not use words such as sometimes or occasionally, but state how many times a week, month, and whether this is to the point of intoxication. Include how many drinks are consumed in one setting and what type of alcohol they drink (i.e. beer, wine, mixed drink, other drink.). Include any experimentation with illegal drugs in their lifetime. Do these statements agree with the criminal history? If not, address this issue. Include rehabilitative activities for each kinship caregiver, if any.

If kinship caregiver reports a current usage or history of alcohol and drug use, assess kinship caregiver’s ability to provide a safe environment for children: Include a statement about any alcohol observed in the home. Address any concerns/issues as it relates to transportation, supervision and protection of the children. ***If caregiver reports current and/or recent drug usage, contact CK Supervisor immediately following interview*** Describe the kinship caregiver's rehabilitative activities, if any: This includes attending AA/NA or if they’ve ever attended rehab. If they attended rehab in the past or report a history of alcoholism and say they are not currently using, how are they managing their triggers? How are they supporting their sobriety? What support do they have? Kinship Caregiver’s Tobacco Use

Does the kinship caregiver use tobacco products (including cigarettes, e-cigarettes, chewing tobacco)? If so, where do they keep their tobacco products when not in use? Do they smoke in the home? Make a statement regarding your observations of ashtrays or smell of smoke in the home.

Kinship Caregiver's history of child abuse/neglect of kinship caregiver Describe kinship caregiver’s history as a victim of child abuse (physical and sexual) and neglect, if any: Include any other child abuse (emotional, physical and sexual) history and neglect, if any, that the prospective caregivers experienced. Make a separate paragraph for each primary caregiver including these details in each. It is often helpful when asking a caregiver about this to ask them how they were disciplined as a child and whether they felt the discipline they received was fair of if their basic needs as a child were met. This could help lead into any other issues around childhood abuse/neglect. However, any abuse or neglect as a child should be discussed. Kinship caregiver's rehabilitative activities, if any: If kinship caregiver has a history of child abuse and neglect, assess kinship caregiver's ability to provide a safe environment for children. Address each kinship caregiver separately. If kinship caregiver was a victim of child abuse or neglect, assess his or her ability to provide a safe environment for children. Address each kinship caregiver separately and give impressions of risk posed by child abuse/neglect history. This means do they have the ability to be protective. What are the caregiver’s thoughts about their abuse? Did they receive counseling to cope with the abuse they experienced? If they did not receive counseling or therapeutic services, do they feel they’ve been able to work through their abuse? Why and how? If they say they just bottled it up or just got over it, other reason, would they encourage this coping strategy in the children that are placed with them, or would they




encourage support and counseling services, or something else. Take all of this into consideration.

Findings from Caregiver's Abuse/Neglect and Criminal History Checks, if any: Create a new paragraph for each household member addressing all required content in this section for each person, if applicable. Be sure to cite the completion date of the criminal background check, if provided. Discuss the self-reported criminal history for each prospective kin caregiver. Address whether any kinship caregiver has lived outside of the State of Texas since the age of 18. If so, document any other states they have resided in and recommend that DFPS conduct background checks in those states. Explain any significant arrests and the circumstances surrounding these charges. Include concerns, background issues, mitigating factors, and any rehabilitations of criminal history such as fines, probation, prison time, recovery program involvement, etc. Address consistency between the self-report and official report. Address inconsistencies with the kinship caregivers. Discuss any child protective services investigations and any history of being a perpetrator of abuse or neglect of children or the elderly for all prospective kinship caregivers. Discuss the results of Central Registry Checks (Please note that FBI and DPS results may not be cited as a source). Explain any subsequent rehabilitative activities by the prospective kinship caregivers regarding any relevant child protective services involvement.

Include your perceptions of how the results of the background checks would affect the health and safety of the child(ren) and assess risk to the child. Were they violent crimes, were they crimes against family members or children, were they many years ago, or recently, did they involve drugs, etc.? Consider this in assessing the caregiver’s ability to protect the safety and what their risk might be to the child(ren). Specifically address if the criminal and/or child abuse/neglect history will affect the ability of the kinship caregiver to adopt or receive adoption assistance (DO NOT ADDRESS ASSISTANCE FOR ICPC-NO BENEFITS ARE GIVEN TO ICPC FAMILIES). Explain to kinship caregiver any potential bar that exists, if any. Include content of discussions, as well as kinship caregiver’s reaction to them. Include any issues relevant to why the placement should be approved, if applicable. No matter what criminal charges/DFPS history exists, a full home study assessment will be provided to DFPS. If DFPS abuse/neglect checks or criminal history reports are incomplete or pending, this should be an area of concern in the study as it must be acquired by DFPS and verified. If a Kinship Safety Evaluation or Program Director approval is required due to their criminal history then please state this in the Summary of Concerns at the end of the study as well. If the potential kinship caregiver has a low-risk criminal offense and are subsequently denied placement based on that offense, inform them that they have the right to appeal the decision REFER TO THE EMBEDDED DOCUMENT FOR ADDITIONAL INSTRUCTIONS IN THIS SECTION—

DOUBLE CLICK THE FILE TO VIEW CONTENT. Low-Risk_Offense_Appeal_Process.pdf

DFPS Criminal History Chart.docx

Findings from Abuse/Neglect and Criminal History Checks for any household member over the age of 14, if any These checks should be addressed the same information required for caregivers. Do not include subject children. CPS or criminal history that operates as a potential bar, if any: Please refer to the Criminal History Chart located on the CK website to determine if any caregiver’s criminal history operates as a potential bar. Please also document per the chart if in any conviction requires a Kinship Safety Evaluation and PD approval. Concerns: Address any concerns as it relates to the type of the offense. If none, please state as such.




Background issues: Include individual’s explanation of circumstances surrounding the criminal/CPS offense. Mitigating factors: Address any sentencing that was court ordered per the criminal background report or by report of the caregiver. This would include services such as probation, parole, fines, and incarceration. Include length of time served as well. Rehabilitation: Address treatments such as drug rehab, AA, anger management, group therapy, church or religion, etc. This would include more therapeutic type treatments. Any other issues relevant to why the placement should be approved: : If a caregiver’s criminal history operates as a potential bar or requires a risk evaluation, ask the family why, despite criminal history, they believe they should be approved for placement. This is not your recommendation, but a report on family’s reasoning for why they believe they should be approved for placement. Write as such. This is a place for the family to make a case for themselves, not the place for the assessor to recommend them. Effect of any CPS or criminal history of an individual in the home on the possibility of future adoption and adoption assistance: Note that you explained that approval to foster or adopt or be eligible for any kinship financial assistance depends on whether the caregiver has disclosed all relevant information to DFPS and on whether a CPS or criminal history emerges follow approval as a kinship home. (DO NOT ADDRESS ASSISTANCE FOR ICPC-NO BENEFITS ARE GIVEN TO ICPC FAMILIES; instead state N/A-This is an ICPC family.)

Effects of CPS and or criminal history of any individual in the home must be discussed with the kinship caregiver. Below, describe that discussion, including the kinship caregiver's reaction: (DO NOT ADDRESS ASSISTANCE FOR ICPC-NO BENEFITS ARE GIVEN TO ICPC FAMILIES; instead state N/A-This is an ICPC family.)

Family Relationships Family of Origin: All cohabitating couples, regardless of legal marital status, need to be addressed as co-caregivers throughout the report. Discuss the kinship caregiver’s family of origin in detail, including information on parents and siblings. If the proposed kinship caregiver is undocumented and/or (illegal alien) document a deportation plan addressing what action would be taken to care for the child if the person was deported or incarcerated. (Note: A person cannot be denied placement solely on the basis of undocumented status—however, this should be a concern in the study and addressed.) If family members are deceased, state when and cause of death. Who raised the caregiver and where? Include information on their relationships with family members past and present. Include names of parents and siblings including current whereabouts. Include any family history of alcoholism, drug abuse, criminality, mental health problems, domestic violence, and involvement with CPS in family of origin. Include pertinent information regarding the kinship caregiver’s childhood experiences (ex: positive or negative experiences; stability; activities). Include how the kinship caregiver was disciplined as a child and if they believe it to be excessive or abusive. When did the kinship caregiver leave home and under what conditions? What is the current relationship with parents and siblings, including frequency of contact and quality of relationship? Previous relationships: This includes previous marriages, people the caregiver has had a child with, someone who the caregiver has lived with or any other relationship the caregiver deems significant. Address each kinship caregiver’s previous relationship history separately with a new paragraph. Include discussions of previous significant relationships as well as all prior marriages. Include




all prior marriages, dispositions of marriages, divorce information, significant others they have lived with or have children by in this section. Request date, city, county, and state of all marriages and divorces. If they cannot provide, document that the caregiver was asked for the information. Describe the history of each past relationship including how they met, the courtship, and the decision to marry, if applicable. If the relationship(s) ended, then include a discussion of how it ended, why it ended, how any differences were resolved, any current contact with that individual, and the type and frequency of contact with that individual. Include any history of family violence in each relationship. Provide details on all biological children from each significant relationship; include both minor and adult children. Include if the caregiver was the primary kinship caregiver of the children, custody arrangements if divorced or estranged, child support payment information, if the person is in arrears on child support, and current contact and relationship with their children. Include pertinent information on each child of the kinship caregiver, including name, date of birth or age, current whereabouts, current lifestyle, occupation, marital status and children, history of alcohol or substance abuse problems, criminal history, juvenile delinquency problems, and involvement with CPS system. Current relationships (married couple): (This section is also for couples living together who are not married. This also includes same-sex couples.) Complete for Couples Only. Request date, city, county, and state of marriages. Include when relationship began if not married and when cohabitated together. Provide details on all biological children from this union, if any. Include both minor and adult children living in or outside the home not previously covered. Include pertinent information on each child including name, date of birth or age, current whereabouts, current lifestyle, occupation, marital status and children, history of alcohol or substance abuse problems, criminal history, juvenile delinquency problems, and involvement with CPS system, if any. Discuss the kinship caregiver’s support system. Describe the kinship caregivers’ interactions as a couple. Explain any separations, marital counseling, and/or history of family violence. Address their decision-making processes (including how they make financial decisions) and how they handle disagreements. Explain how adding a child(ren) to the household could affect the family. Describe the strengths and needs of their marriage, (What do they like/dislike about each other? How would each describe the other? What do they enjoy doing together?) including the couple’s and the worker’s perceptions. Describe the emotional support systems each applicant has outside their relationship. Describe how the couple feels about themselves as parents. Describe whether the couple has realistic expectations of the children that may be placed in their home. Provide details on the parenting experiences of the caregivers. Describe the dating habits of the couple and how this may be altered with a child in the home. Couples with children: Discuss the kinship caregiver’s support system. Describe how the couple interacts as parents. Explain the aspects of parental discipline they agree and disagree on. Explain how the couple resolves disagreements. Describe how they support one another as parents. Include any evidence of possessiveness, excessive control, and so forth. Include how the couple feels about themselves as parents. Discuss the effects of adding a child(ren) to the home. Describe whether the couple has realistic expectations of their children and the children that may be placed in their home. Describe emotional support systems they have. Provide details on the parenting experiences of the caregivers with their own children even if the children are adults. Section is only N/A for single parent caregivers. Address this section for any couple that has children together or if they are raising children from previous relationships. If the couple’s children are adults, address this section as to how the couple handled these things when their children were younger. If a couple has never had children, address this section with them as if the subject children were in the home.

Single parent caregivers: Discuss the kinship caregiver’s support system. Discuss any significant relationships the kinship caregiver has with both men and women. Describe the dating habits of the single parent and how this may be altered with a child in the home. Determine if there is a current paramour and, if so, list name and relationship details such as relationship history, length of relationship, does the person spend nights in the home, alcohol and illegal drug use history of the paramour. Make attempts to interview the paramour and include all information (including background checks) as required for other




household members. Describe how the kinship caregiver feels about him or herself as a parent. Discuss the effects of adding a child(ren) to the home. Describe the realism of the expectations of the children that may be placed in the home. Describe emotional support systems they have. Provide details about the caregiver’s parenting experiences, even if the children are adults.

Children Currently in the home: Interview each child in the home separately and provide information on each child in a new paragraph. Provide basic information on the children such as name, age, grade in school, hobbies, extracurricular activities, or other personal details. Ask the child(ren) currently living in the home about discipline, family rules, visitors, babysitters, parental disagreements, his/her opinion/perception of the family’s decision to provide care to another child, etc. If age appropriate, determine if there is alcohol or drug abuse with the child, criminal history, or CPS history. Report his/her perceptions, your own, and your observations of the child(ren)’s interaction with parent(s). If child is non-verbal, describe the child and condition observed. PLEASE NOTE – if a child does not respond to the questions, document the attempts to interview, the questions asked, and describe the child's responses to the interview (non-verbal and/or behavioral responses). Children MUST be interviewed in the home and alone. They may not be interviewed at school. Other household members: Discuss other household members, including anyone who resides in the home part-time (or who visits daily). State the relationship they have to the kinship caregivers. Include history of alcohol/drug abuse or present use of alcohol/drugs and any history of child abuse. Criminal background checks and Central Registry (DFPS) background checks are required on other household members. If this information has not been provided, indicate that as a concern at the end of the study. Detail the role this person plays with the children in the home or will play with children placed in the home. All household members must be interviewed in a Face-to-Face contact. Ensure that you make it clear what the role will be of any additional adult household member, meaning will they provide child care or be responsible for the child in any way. If not interviewed, explain why and list this as a concern at the end of the study. In the event household members are deployed with the military, it will be required to conduct a telephone interview or email communication to gather information required for the home study. Frequent Visitors: DEFINITION OF FREQUENT VISITORS: Individuals who are frequently present at the residence: More than two non-continuous visits at your home in a 30-day period; one continuous stay per year at your home and the duration of the stay exceeds seven days; or more than two continuous stays per year at your home and the duration of each stay exceeds 48 hours. Frequent visitors to the home should be documented in this section, including criminal background checks and DFPS background checks. If a person is determined to be a Frequent Visitor, you should request the applicable background checks on these individuals as well and utilize the same criteria in evaluating criminal and CPS history as the potential caregivers. If it is determined that the perpetrator of the child abuse is living in this home (such as the parent from whom the children were removed), then the DFPS caseworker must be notified immediately. If the family denies any frequent visitors, state as such. If references contacted indicate they are frequent visitors to the home, include them in this section. Family Functioning Kinship caregiver health (physical, mental and emotional of each kin caregiver): Address each kinship caregiver’s health separately with a new paragraph. Include an assessment of each kinship caregiver’s physical, mental, and emotional status in relation to the kinship caregiver’s ability to parent the child(ren) to be placed with the kinship caregiver. Include information on each prospective kinship caregiver including details on their physical health, history of hospitalizations (this includes child birth), all mental health history (current/past diagnoses/treatment), and current prescription medications/reason for




medication taken. How does the medication affect their ability to care for the children? Discuss any disabilities the kinship caregiver has, the adjustment to the disability, any limitations the disability may impose on their ability to provide safety, permanency, and well-being for the child(ren) to be placed. Be sure to address for controlled medications (ie pain pills): how often are they taken? how long have they been taken? what are the side effects of the meds? how does the medication affect their ability to care for the children? ***IMPORTANT NOTE: NEVER disclose that a person has a life-threatening condition (such as HIV or AIDS) in a home study evaluation. It is a violation of federal law to disclose a person’s HIV status, even if they disclose this to you during the study. Rather, state that the person has a “life threatening illness” (this is DFPS’s preferred language). If a prospective kinship caregiver discloses a life-threatening diagnosis, a recommendation for a physician's statement regarding the person's ability to parent should be made. Family rules and boundaries: Discuss the family’s rules, expectations, responsibilities, division of labor, privacy. Include caregiver’s feelings/boundaries regarding nudity. Please do not state there is no nudity in the home. Instead, you can state there is no open nudity or no nudity in the common areas of the home. Handling Stress and Expressing Negative Feelings: Include how the kinship caregiver responds to stress and negative feelings. Include how the prospective kinship caregivers spend their free time. Include examples of statements and behaviors that support your assessment. Kinship caregiver’s home: Address the kinship caregiver’s ability to provide a safe home environment. Information should include sleeping arrangements before and after placement, appropriateness of sleeping arrangements. Consider co-sleeping and sharing rooms, and what is their plan for beds if none are present. Describe the bedroom(s) designated for children to placed. Include adequacy of space for children to play both inside and outside, pets in and outside of home, physical verification of pet vaccinations, fire alarms, swimming pools, trampolines, physical environment (including cleanliness), storage of hazardous materials, prescribed and non-prescribed medication; and physical hazards noted. For pets, document breed type, disposition and names; document pet vaccinations were viewed; if not, describe family’s willingness to produce, if asked. If hazardous materials, cleaning supplies or medications are within reach of children, please address if the caregiver is willing to move or store them differently if requested. Explain proximity of home to the CPS child(ren)’s biological parents. Clearly state you walked through the entire home. Assess residence stability as justified by the 10-year history listed below. If they’ve moved frequently, why? Are they stable now, what indicates stability currently? Provide 10-year history of residences for the potential caregivers: Delete unused rows. If the residences differ between the two main caregivers, duplicate this table and make two tables for clarification.

Dates at This Residence Street Address & City Reason for Moving

Situational Safety Issues: Discuss with the kinship caregiver issues regarding the importance of proper supervision of each child that could potentially be placed with the caregiver taking into consideration the child’s age and past experiences. Include infants, school age children, both young and teenage (teenagers often require supervision as well), daycare arrangements, etc. What do they believe is appropriate supervision




for the age(s) of the child(ren) they are being considered for? CPS is not always able to offer financial support for child care, so what can the Kinship caregiver do in order to supervise the child(ren) without added support? Ask the kinship caregiver if anyone in the household owns a weapon, such as a firearm. Address whether the caregiver understands the importance of proper weapon storage. Assess if the caregiver knows how to properly store the weapon(s), including ammunition. If they do not, discuss with the caregiver how to keep the weapon, including firearms, away from children. Address whether the kinship caregiver understands the importance of water safety regarding recreational activities, such as swimming in swimming pools or lakes as well as bath tub safety. Assess whether the caregiver knows how to supervise the child around water taking into consideration the child’s age, (state what they believe is appropriate considering the subject child’s age), and if the caregiver knows how to respond if an emergency occurs. If they do not, discuss with the caregiver how to keep the child safe around water and how to respond in case an emergency occurs. Safety, related to child(ren)’s issues: Discuss the kinship caregiver’s understanding about the problems the child(ren) may have and how the kinship caregiver will deal with those problems. (health problems, behavior problems, developmental problems, educational problems, etc.). Explore the kinship caregiver’s ability to protect the child from the child’s parents or other caregivers who may pressure them to return the child to the parents or other caregivers. Document how the caregivers would respond if pressured. Report the kinship caregiver’s perceptions and your own. Discipline: Discuss the kinship caregiver’s values (parenting philosophy) regarding child discipline and care (what is their parenting philosophy and what do they believe is the purpose of discipline?). Describe the kinship caregiver’s current methods of disciplining children and their feelings on the subject. If their current disciplinary practices are incompatible with those endorsed by DFPS, then how do they plan to reconcile their practices with DFPS's policies? Include the applicants' ability to support DFPS's discipline policy. Child-care knowledge: Discuss the kinship caregiver’s child-care experience if they have had no children. Address the caregiver’s expectations of the child(ren) to be placed and of working with the child(ren). Are these expectations realistic? (Consider age of the children being placed—does the caregiver have an understanding of characteristics/needs of children of specific ages—infants, elementary age, teenagers, etc.) Include examples of behaviors and activities that can help facilitate discussions about how best to meet goals. Include the caregiver's expectations about visiting the child's school, monitoring the child's performance in school, handling public displays of inappropriate behavior by the child, and so on.

Child management: Discuss the kinship caregiver’s ability to help the child(ren) and ability to manage the behaviors of a child(ren) who has experienced neglect and/or abuse, such as sexual acting out, aggression, abusive language, stealing, bedwetting, food issues, needing light on at night, fear of baths, etc. If the caregiver is aware of specific behaviors related to the subject child, address how they will handle those. Emergency Care Plan: Discuss kinship caregiver's plan to ensure the continuity of care for the child(ren) placed in case of unexpected events such as hospitalization. Unexpected events could also include being called into work, family emergency, etc. Does the caregiver have someone they could contact to care for the children immediately in one of these situations? If this person is a household member or reference, note if the person confirmed this plan or not




Financial situation: Identify each prospective kinship caregiver’s employment history for the last 10 years and assess employment stability (include work days/hours). Include information on household personal savings, assets, income, expenses, and ability to manage money. Verify all income claimed by reviewing current pay stubs, and state you did so (chart should list net income; add gross income here if provided by caregiver). Include if family has adequate reliable transportation (this includes make/model of vehicles). Include any relevant information on family health insurance coverage. Ensure to address all expenses listed with the caregiver. If any reasonable expense is listed as $0, such as clothing, entertainment, auto insurance, etc., address this with the caregiver to ensure accuracy or document the reason why. If something is $0 because it is paid for, please indicate. Monthly expenses can be averaged; for example, if a family spends $500 per year on clothing, you can note $42 for the month. ***Type this information above the chart***




Assess if the expenses disclosed by the family are realistic. For example, amounts listed for groceries appear adequate for the family, utilities appear realistic for the home, etc. Address the kinship caregiver’s ability to manage the expenses of caring for the placed child(ren) without additional financial assistance. Discuss any concerns with financial ability and the impact of additional child care expenses on the family budget. (How does the family plan to pay for daycare/afterschool care expenses if needed?)

Net Monthly Income:

USE $ on all amounts

listed.

Monthly Expenses: USE $ on all amounts

listed.

Kin Caregiver #1: Rent/Mortgage

Kin Caregiver #2: Vehicle Payments

Other: Car Maintenance & Fuel

Water Electric Gas Telephone Cable Internet

Groceries

Medical Care Not Covered by Insurance

Child Care Expenses

Health and/or Life Insurance Premiums

Auto Insurance

Credit Card Payments (Total Credit Card Debt: )

Child Support Payments

Clothing

Personal Loans

Entertainment

Other Debts/Expenses: Specify:



Total Monthly Income

Total Expenses




Discuss resources that may be available to the kinship family that will help support the placed child(ren). Example: child support, Medicaid, TANF, other family members, etc. FOR ICPC ONLY: there are no state resources (INCLUDING DAYCARE), as the children are not in the custody of Texas. Instead, state: The family was directed to the referring state for resources to help with the children. (DO NOT ADDRESS ASSISTANCE FOR ICPC-NO BENEFITS ARE GIVEN TO ICPC FAMILIES) Clearly state that the family was informed that there will likely be limited or no financial assistance on kinship placements. ***Type this information below the chart.*** Permanency Child(ren)’s involvement with the kinship caregiver: Describe the prospective kinship caregiver's previous and current relationship with the child(ren). How often did they have contact, daily, weekly, monthly, special occasions and holidays, etc.? If they have never met the child, state this. Assess if they have ever provided care for this child in the past and to what degree (overnight care, weekend care, summer care, after school care, etc.). Include the child(ren)’s feelings about the kinship caregiver(s), if known. Include how the kinship caregiver perceives the child to feel about them. Kinship Caregiver's plan to support the child(ren)'s permanency plan: Describe the kinship caregiver’s understanding of the current permanency goal and the caregiver's ability to support the permanency goal. Determine if the kinship caregiver(s) desire is to have the child(ren) placed temporarily or permanently and how this compares with the Department’s desires. (Check the referral documents for the Department’s permanency plan and state it; it is often times found on form 6581). Determine if the kinship caregiver is willing to adopt the child if this is necessary at a later date and their feelings regarding this subject. Report the kinship caregiver’s perceptions. Explore how the potential kinship caregiver feels about allowing parental visitation and contacts. Include the kinship caregiver's willingness to cooperate with visitation, help develop and follow through on the child's service plan, and help the child stay in contact with the child's siblings. Include all sibling information that is known, the whereabouts of the siblings, and relationship with child to be placed, if any. (Ask the caregiver if they are aware of any siblings and their whereabouts). Report the caregiver’s perceptions and your own. Well-Being Children to be placed: Have the kinship caregiver describe the child to be placed. Include all known placements of child(ren) proposed for placement. Include any health issues, mental health problems, known specific behavioral problems, prescription medications, and any special care needed for each child proposed for placement. Address how the kinship caregiver will meet the medical, dental, therapeutic, social, and academic needs of the child(ren) to be placed. Include the child’s level of success in school, both academic and behavioral. Include any known behavioral problems and plans to deal with those problems. Detail the kinship caregiver’s plans for providing childcare for the children. Assess appropriateness of childcare arrangements. Dealing with children who have been physically, sexually abused and/or neglected: Address the kinship caregiver’s sensitivity to and feelings about children who may have been subjected to abuse and/or neglect. Include the kinship caregiver’s understanding of how these issues and feelings will affect him/her as well as the child(ren). Address the kinship caregiver’s ability to help the child who has experienced abuse and neglect. State the caregiver’s feelings towards children who have been abused or neglected. Document the caregiver’s understanding of the effects that physical, sexual, abuse or neglect may have on a child and how the caregiver will help them (what can they and their home provide?) State if the caregiver is open to professional resources.




Relative Support Systems

Needed supportive services: Identify support services that may be needed by the kinship caregiver to help him/her provide for the child(ren)’s safety, permanency, and well-being. Examples of potential support services could include daycare services, tutoring services, training, specialized counseling, etc. Kin caregiver’s plan to use identified family and community supports to meet the needs of the children: Identify the family and community supports they plan to use. If the kinship caregiver is ill or elderly, identify and discuss the caregiver’s backup plan for the child.

References The kinship caregiver must provide two related references and three non-related references, in addition to references from all adult children. Attempt to contact all references three times over the course of three different days (not three attempts on the same date). If the caregiver cannot provide the required references, do not sub one for the other and list it as a concern. References must be contacted by phone unless otherwise approved by CK Supervisor. The kinship caregiver must provide two related references, three non-related references, in addition to references from all adult children. If you need additional lines, simply use the tab key in the far-right column. Interview forms for adult children and other references are provided for data collection purposes.

Relative and

Personal Reference Q

Summary of adult child references: Make an attempt to contact all adult children—including the parent of the child being placed, if the kinship caregivers are grandparents to the child. Document attempts if they are non-responsive and list as a concern at the end of the study. Address their comments about the kinship caregiver’s parenting style. How were they disciplined as children? Summarize positive statements and address concerns raised by each adult child. Each adult child reference should be identified and recorded separately with a new paragraph listing the adult child’s name, and comments as described above. If an adult child lives outside the country, request that the potential caregiver have this adult child contact you to conduct a phone interview. Include interviews/attempts in table above.

Adult Child Reference Questions. Summary of positive references: If information from the kinship caregiver’s references is positive, summarize those comments briefly using direct quotes. Each reference should be identified and recorded individually by a new paragraph for each reference listing the reference name, relationship to the kinship caregiver, their opinion about the placement, and the comments describing the kinship caregivers. References provided that live outside the country are not required to be contacted via phone by the

Name Of Reference Date Of Contact

Relationship To Subject of Study

Location/Type Of Contact

(Include Phone Number)




subcontractor. Each reference should be identified and recorded individually by a new paragraph for each reference listing the reference name, relationship to the kinship caregiver, their opinion about the placement, and the comments describing the kinship caregivers. References provided that live outside the country are not required to be contacted via phone by the subcontractor. Summary of negative references: If information from the kinship caregiver’s references raises any concerns, address the concerns carefully. Each reference should be identified and recorded individually by a new paragraph for each reference listing the reference name and the comments describing the kinship caregiver. Also include a statement here if any references were unable to be contacted and if messages were left. Issues identified in the Risk Assessment Make the following statement and then explain/summarize the risk assessment: A risk assessment was conducted by your name, your credentials on xx/xx/xx. Based on documentation provided in the referral, face to face interviews and observations, and reference reports, (some risk, significant risk, minimal risk, etc.) was identified in the home at the time of the home study.

State the risk factors that were checked yes and your rationale for the level of risk/concern. Briefly summarize Risk Assessment results. If there are any identified concerns in the risk assessment, this section should include the risk identified, the relevant background, mitigating factors, rehabilitation, and other issues relevant to why the placement should be approved in light of the concerns.

Home Screener’s Recommendation Based on the facts of the case, the observations and interviews conducted during the home study assessment, as well as contacts made with collateral references, this interviewer identified the following strengths and areas of concern regarding the potential placement:

Summarize the strengths: LIST STRENGTHS IN BULLET POINTS. Ensure that all pertinent strengths of the placement identified throughout the home study assessment are summarized. Consider the following when addressing a caregiver’s strengths:

• Familiar with child, strong relationship • Parenting experience; parenting skills (by your observation or by history) • Desire, willingness, commitment • Committed to protecting child from harm • Willing to comply with DFPS plan for ongoing contact and permanency • Strong support system • Cleared criminal background check, “no hits” • Adequate space within home indoor and outdoor • Clean and safe home environment • Financially secure; job stability • Ability to seek and secure community resources • Education level • Experience in caring for specific medical, developmental, behavioral or therapeutic needs

the specific child may experience • Good communication skills • Cooperative, flexible • Realistic expectations




• Nurturing, supportive, loving, calm, patient • Ability to manage stress and pressure successfully and calmly

Summarize any concerns: LIST CONCERNS IN BULLET POINTS. Ensure that all pertinent concerns and risk identified throughout the home study assessment are summarized. If a Kinship Safety Evaluation and/or Program Director approval is required due to their criminal history then please state this here [i.e. “Due to the caregiver having a Misdemeanor Theft charge in 2012, DFPS needs to conduct a Kinship Safety Evaluation and seek Program Director’s approval]. Consider the following when addressing concerns:

• CPS history/concerning criminal history • Inadequate housing (too small, unsanitary, etc.) • Some environmental problems but correctable (pests, holes in wall, construction, clutter) • Questionable parenting skills (by observation or by history) • Unresolved abuse history • Mental health issues; mental illness untreated • Physical health concerns (illness, elderly, disability, etc.) • Lacking financial resources; unemployed, job instability • Limited or ineffective communication skills • Anger control issues • Inexperience in managing behavioral/emotional issues specific to child in question • Inability to secure alternative childcare plans, day care and summer care • Limited intellectual functioning • Personal boundaries leading to family dysfunction, roles, behavior patterns • Due to age, inability to parent into adulthood; no guardian identified • Transportation difficulties • Poor coping skills/ways of managing stress

Required Attachments:

• Signed Kinship Release of Information and Acknowledgement Form for all Household Members age 18 or over.

• Completed Risk Assessment Form




SIGNATURE PAGE

IMPORTANT: The content of this home assessment was developed based on limited contact with the family and collateral contacts. Efforts have been made to verify the content of this study when possible; however, due to the nature of the assessment, a considerable amount of the information contained in this report was gathered through self report by the prospective caregivers. The signature below reflects the submission of the Home Screener assessment ONLY and NOT the approval of the respective home. This signature verifies the Home Screener has prepared the home assessment in compliance with applicable State Standards. Home Assessment Completed by:

Name of Home Screener, Credentials TYPE YOUR INFO IN GREY BOX Date Include License Number, if applicable: Home Assessment Reviewed & Approved by, if Applicable:

Name of Quality Managment Team Lead, credentials CK SUP GOES HERE Date Delivered to Field Supervisory Staff, Date: ____________________

Reviewed by a DFPS/CPS Program Director or Designee: Date: ___________________

CPS Field Supervisory Staff Action: I acknowledge that I reviewed this home assessment and identified concerns, if any. The following steps will be taken to address identified concerns:

PLACEMENT APPROVED

PLACEMENT NOT APPROVED (Justification must be documented on Form 0699)

____________________________________________________________________________ CPS Supervisor’s Printed Name CPS Supervisor Title

__________________________________________ Date: _________________

CPS Supervisor’s Signature __________________________________________ CPS Program Director Printed Name (if applicable) ___________________________________________ Date: _________________ Program Director Signature (if applicable)

kinship caregiver home assessment

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