CP&P Form 26-53c
(rev. 12/2006)
State of New Jersey
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Child Protection and Permanency
INDIVIDUAL AND FAMILY ASSESSMENT OUTLINE-ADOPTION
Child Summary Outline-Part B
I. Child to be Adopted
Name:
Date of Birth:
Place of Birth:
Race:
Sex:
Ethnicity:
Religion:
Social Security Number:
NARRATIVE: Worker should know child well enough to personalize this section by focusing on what makes this child special, likable and unique. For children age three and under, it is permissible to combine the elements of Section I and Section II into one overall child narrative.
Provide a current description of the child in the following areas:
· Personal Attributes: physical description, personality traits, individual abilities, special
needs, likes/dislikes, etc.
· Educational Information: name of school child attends, grade level, behavior as reported by school, current classification (if any), academic performance, special services child receives, educational goals, extra curricular activities, etc.
· Social Relationships: behavior with adults and peers, response to adult guidance, response to discipline, interaction with other children, participation in child-specific activities (scouts, sport teams, church groups), social aptitudes.
· Family Relations: attachment to birth parents, attachment to siblings, need for continuing contact with specific family members, connections to foster siblings, etc.
· Health: diagnosed or reported mental or physical conditions, need for specialized care, routine medical care, etc. If the child is medically fragile, include a full description of the reason for this classification. If the child has since been de-classified, detail the child’s actual improvements and include the date the child was de-classified.
· Knowledge & Understanding knowledge of own birth family history, understanding of placement
of Adoption: situation, understanding and acceptance of adoption; include information about the child’s preparation for adoption and reaction to it.
CP&P Form 26-53c
(rev. 12/2006)
II. Birth and Developmental History
Narrative description of the child from birth using factual information from hospital records, medical records, school reports, psychological or psychiatric evaluations and therapy reports. The summary must include the date and result of all medical, psychiatric or psychological testing completed on the child even if the outcome did not reveal long-lasting problems.
· History of prenatal care, time and place of birth, type of delivery, APGAR scores, weight and length at birth, medical concerns/treatment, date and result of HIV testing (if applicable), date and result of drug screening (if applicable) and whether child experienced drug withdrawal at birth, physical description as noted in birth records.
· Age at which child reached developmental milestones such as sitting up, crawling, walking, talking, toilet training, self care, etc. Note any specific difficulties or services child required.
· Abuse or neglect experiences
· Placement history
· Educational experiences; Child Study Team evaluations
· Medical and health history that includes diagnosed or reported emotional, mental or physical conditions, tests and results related to these conditions, specialized care, routine medical care, special needs.
III. Reason for Adoption Plan
Describe the circumstances which lead to the selection of adoption as the case goal in a clear, concise summary that is informational in tone rather than legalistic. The goal of this section is to develop a narrative social summary that highlights family history, including both positive and negative aspects.
· General overview of CP&P involvement with family.
· When and why this particular child entered resource family care and the persistent family problems that lead to a failure to reunify child with family.
· Indicate how and when the child became available for adoption and whether current adoption plan is resource parent adoption or placement in a selected adoptive home.
IV. Family Information
A. Birth Mother: narrative description of the birth mother includes:
· Individual Traits – date and place of birth, race, religion, nationality/ethnicity, physical description, personality, skills and interests
· Social History – family background, marital/civil union history, social relationships
· Education and Employment History
· Parenting Role – age when first child was born, available family support (or not), caregiving abilities and deficits, history of relationship with child, etc.
· Feelings about adoption and/or hopes for child
CP&P Form 26-53c
(rev. 12/2006)
B. Birth Father: narrative description of the birth father that includes:
· Individual Traits – date and place of birth, race, religion, nationality/ethnicity, physical description, personality, skills and interests
· Social History – family background, marital/civil union history, social relationships
· Education and Employment History
· Parenting Role – age when first child was born, available family support (or not), caregiving abilities and deficits, history of relationship with child, etc.
· Feelings about adoption and/or hopes for child
C. Siblings: narrative description of each sibling that includes:
· Biological Relationship (brother, sister, half-brother, half-sister)
· Individual Traits – date and place of birth, race, religion, ethnicity, physical description, personality, skills and interests
· Education and Health History
· Relationship with Child to be Adopted – have these children lived together, is there a history of sibling visitation, how do children interact with each other, etc.
· Present Living Situation and Permanency Goal
V. Adoption Placement Issues
Include in this section information specific to this child’s adoption:
· legal status
· involvement with ongoing sibling visitation
· child’s understanding and acceptance of adoption plan
· preparation of child for adoption
· Life Book status
· specific need for any post-placement services
Prepared By (Print Name): Date:
VI. Signatures and Dates
Permanency Worker: (Name) (Signature) Date
Adoption Specialist: (Name) (Signature) Date
Supervisor of Permanency Worker: (Name) (Signature) Date
Adoptive Parent Date
Adoptive Parent Date
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