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FAMILY SAFETY, RISK, AND PERMANENCY (FSRP) SERVICES

CASE TERMINATION SUMMARY

Billing Child Name / DHS Case Manager Name
County / Case Referral Date
State ID / Case Closure Date
Case ID / Termination Summary Date
Date Termination Summary was provided to DHS Case Manager
Date Termination Summary was provided to the Parent(s)
Author of Termination Summary – FSRP Care Coordinator Name
Placement Status of Children
Reason for Referral

Goals/Behavioral Outcomes

Current Reporting Period Updates
Goal 1: / Completion Date:
Service Plan Objective:
Service Plan Objective:
Interventions/Strategies Utilized:
Referrals/Resources Utilized:
Behavioral Outcome Progress:
Goal 2: / Completion Date:
Service Plan Objective:
Service Plan Objective:
Interventions/Strategies Utilized:
Referrals/Resources Utilized:
Behavioral Outcome Progress:
Goal 3: / Completion Date:
Service Plan Objective:
Service Plan Objective:
Interventions/Strategies Utilized:
Referrals/Resources Utilized:
Behavioral Outcome Progress:
Goal 4: / Completion Date:
Service Plan Objective:
Service Plan Objective:
Interventions/Strategies Utilized:
Referrals/Resources Utilized:
Behavioral Outcome Progress:

Service Provision Contacts/Attempted Contacts

Face-to-Face Family Contact or Attempted Contact

Date
Location
Participants Names
Start-End Time
Summary of Service Provision or Attempt
Service Plan Goals Addressed

Face-to-Face Family Contact or Attempted Contact

Date
Location
Participants Names
Start-End Time
Summary of Service Provision or Attempt
Service Plan Goals Addressed

Face-to-Face Family Contact or Attempted Contact

Date
Location
Participants Names
Start-End Time
Summary of Service Provision or Attempt
Service Plan Goals Addressed

Face-to-Face Family Contact or Attempted Contact

Date
Location
Participants Names
Start-End Time
Summary of Service Provision or Attempt
Service Plan Goals Addressed

Safety Constructs

Overall assessment of Threats of Maltreatment, Protective Capacities, Child Vulnerability, Underlying Conditions and Contributing Factors

Termination Information

Provide a description of the following:
·  Identified safety concerns and risk factors that were present;
·  Behavioral outcomes achieved to eliminate safety concerns and reduce risk factors;
·  Intervention/strategies provided to achieve outcomes;
·  How ensure outcomes will be sustained;
·  Current child and family functioning as well as impact of services on functioning;
·  Family and community supports that were implemented and will serve as resources; and
·  Overview of case progress, including case status.
Care Coordinator Signature: / Date:
Supervisor Signature: / Date:
January 2017 - Page 1