Quarterly Progress Report on Child in State Custody
1. / Date of Report: / 2. / Family Service Worker:
3. / Child’s Name: / 4. / D.O.B.:
5. / Parent(s) / Caregiver(s): / Name / Relationship
a.
b.
6. / Parent(s) / Caregiver(s) City:
7. / Date of Custody: / 8. / Adjudication: / a. / Unruly / b. / Delinquent / c. / Dependent-Neglect
9. / a. Date Current Permanency Plan Developed: / b. Date Current Permanency Plan Ratified:
10. / Date Last Permanency Plan Held:
11. / Permanency Plan Goal(s): / Return to Parent / Exit Custody With Relative / Adoption
Permanent Guardianship / Planned Permanent Living Arrangement
12. / Current Placement - / Name of Resource Family/Facility:
City/Town of Placement:
Placement Start Date:
13. / Summary of Child/Family, Child/Sibling Visitation: (Give dates of visits and visitation summary since last quarterly report)
14. / Please rate the quality of the visitation: / Excellent / Good / Marginal / Poor / N/A (TPR)
Please explain ratings less than good:
15. / Describe efforts made this quarter to locate absent parents or identify relatives: (County Clerk, Police Records, Utilities records etc.))
16. / Educational Needs : / Name of School:
Grade: / K123456789101112GEDNot in SchoolToo young for school / Date Last S or M team meeting: / Not Applicable (N/A)
IEP: / Yes / No/N/A / 504 Plan: / Yes / No/N/A
17. / Please rate the child’s progress in school: / Excellent / Good / Marginal / Poor / N/A (not in school)
Please explain ratings less than good:
18. / Medical/Dental Needs:
Date of Last EPSD&T Needs/Concerns: / Date of Last Dental Needs/Concerns:
19. / Please rate the child’s overall health: / Excellent / Good / Marginal / Poor
Please explain ratings less than good:
20. / Needs and Goals of Child/Youth:
(As indicated in the Permanency Plan. Also list progress made since last review and remaining barriers.)
Health – Medical/Dental:
Education:
Independent Living Skills (14 +):
Therapeutic/Treatment Needs:
Other:
21. / Permanency Plan Progress:
(List the goal and action steps associated with the goal, progress made since last review and remaining barriers. If goal is concurrent, also list the actions steps associated with the concurrent goal).)
Goal:
Action Step / Progress
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
22. / Concurrent Goal (if applicable):
Action Step / Progress
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
Excellent Good Marginal None
23. / Next Steps: (To be completed during Quarterly Review with those present or at FCRB)
Task / Name of Person Assigned to Task / Date to be Completed
24. / A.S.F.A. Review (Compelling reason to not file Petition for TPR) (Note: N/A unless the child has been in care over 12 months with a reunification goal)
25. / Signatures:
Child/Youth / Date
Parent / Caregiver / Date
Family Service Worker / Date
Supervisor / Date
Always check the “Forms” Website for most current version and disregard all previous versions. This form may not be altered.
Distribution: Child age 12 and older, Parent/Guardian, Resource Parent, Review Board Chair and Child’s Case File
CS-0430, Rev. 05/07 Page 1 of 3