Alternative Response Assessment

Alternative Response Assessment

Case Name / Case Number
[TM1] / [TM2]
Referral Date / Date Worker Assigned
[TM3] / [TM4]
CHILD INFORMATION
Child Name / Birthdate
[TM5] / [TM6]

END_DYNAMIC_TABLE=CHILDREN

PARENT INFORMATION
Parental Role Name / Birthdate

START_DYNAMIC_TABLE=PARENTS

[TM7] / [TM8]

END_DYNAMIC_TABLE=PARENTS

I. / CONTACT
Document the interview protocol, contacts, and meetings related to the completion of the initial assessment.
First Contact
Date  First face-to-face contact with family member / Time  First face-to-face contact with family member
[TM9] / [TM10]
Contacts (Include first contact listed above)
Date / Time / Participant / Note Type / Location / Result / Case Note ID
[TM11] / [TM12] / [TM13] / [TM14] / [TM15] / [TM16]

START_DYNAMIC_TABLE=CONTACTS

END_DYNAMIC_TABLE=CONTACTS

II. / NARRATIVE FIELDS

Describe the Presenting CPS Issue, Family Strengths and Needs

Describe the issues occurring in the family that have brought them to the attention of CPS. Describe both the strengths and needs identified in the family.

[TM17]

Safety Assessment
[TM18] / One or both parents / caregivers intend(ed) to seriously hurt the child.
[TM19] / Living arrangements seriously endanger the child’s physical health.
Child(ren)'s Functioning
Describe the child(ren)’s general functioning and effects of any maltreatment.
Child Name
[TM20]

Description

[TM21]

END_DYNAMIC_TABLE=CHILD_FNCTNG

Safety Assessment
[TM22] / The child is profoundly fearful of the home situation or people within the home.
Adult’s Functioning
Describe each adult's general functioning, daily life management, mental health functioning and substance use.
Parental Role Name
[TM23]
Description
[TM24]
Safety Assessment
[TM25] / One or both parents’ / caregivers’ behavior is dangerously impulsive or they will not / cannot control their behavior.
[TM26] / One or both parents / caregivers are violent.
Disciplinary Approaches and Parenting Practices
Describe the disciplinary approaches generally used by the parent and the typical context within which they are used. Describe the parents' general parenting practices (nurturing, limit setting, protectiveness, provision of basic care, etc.).
Parental Role Name
[TM27]
Description
[TM28]
[TM29]
Safety Assessment
[TM30] / The child has exceptional needs which the parents / caregivers cannot / will not meet.
[TM31] / No adult in the home will perform parental duties and responsibilities.
[TM32] / One or both parents / caregivers fear they will maltreat the child and / or request placement.
[TM33] / One or both parents / caregivers lack parenting knowledge, skills or motivation necessary to assure the child’ basic needs are met.
[TM34] / One or both parents / caregivers have extremely negative perceptions of the child.
[TM35] / Family does not have or use resources necessary to assure the child’s basic needs.
Family Functioning
Describe the family’s general functioning, strengths, and current stresses. Consider the family’s cultural context.
Description
[TM36]
III. / CONCLUSIONS
Safety Assessment and Conclusion:
Yes / No
[TM37] / [TM38] / One or more factors that negatively affect safety.
Date of Safety Assessment: / [TM39]
If the answer to the above is "No", then the child(ren) is / are safe. Proceed only with required documentation of contacts, interview, content or observations, and supervisory approval.
If the answer to the above is "Yes", then the child(ren) may be unsafe. Proceed to the Safety Assessment and Planning to consider the parent / caregiver protective capacities and the need to control for safety.
IV. / ASSESSMENT RESULTS
Alleged Victim / Relationship of Alleged Maltreater to Victim / A / N Code / Description / Assessment Results

START_DYNAMIC_TABLE=MaltreatmentInfo

[TM40] / [TM41] / [TM42] / [TM43] / [TM44]

END_DYNAMIC_TABLE=MaltreatmentInfo

V. / DISPOSITION
[TM45] / Case Closed
[TM46] / Child(ren) Safe
[TM47] / Child(ren) Safe – Referred to Community Services
[TM48] / Clients Unavailable or Cannot be Located
[TM49] / Family Refuses Services – No Court Jurisdiction
[TM50] / Case Opened
[TM51] / Case opened for on-going CPS services: Voluntary
[TM52] / Case opened for on-going CPS services: Petitioned
[TM53] / Case opened for non-CPS services
[TM54] / Case currently open for on-going CPS services: Voluntary
[TM55] / Case currently open for on-going CPS services: Petitioned
[TM56] / Case opened – BMCW safety services
VI. / CLOSING SUMMARY / SUPERVISOR COMMENTS
Include any referral to community resources that were made:

[TM57]

VII. / CORRESPONDENCE
Mandated Reporter
[TM58] / Not applicable (non-mandated reporter)
Date mandated reporter given feedback: / [TM59]
Relative Reporter
[TM60] / Not applicable
[TM61] / Documented request for information received from relative reporter: / [TM62]
[TM63] / Date Letter Sent: / [TM64]
OR
Date of Court Order Barring Disclosure: / [TM65]
VIII. / SIGNATURES
[TM66]
Name – Worker
SIGNATURE – Worker / Date Signed
[TM67]
Name – Supervisor
SIGNATURE – Supervisor / Date Signed

Alternative Response Assessment

DCF-F-2493-E (R. 10/2012)Page 1 of 3

[TM1]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Name field on the Maintain Case page.

[TM2]This field is pre-filled (system generated).

This field is not editable on the template.

[TM3]This field is pre-filled (system generated).

This field is not editable on the template.

[TM4]This field is pre-filled.

This field is not editable on the template.

The data cannot be corrected. The Date Worker Assigned is the actual date when the worker was assigned.

[TM5]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Add/Edit button and selectthe desired Child Name(s) from the list of Case Participants on the Participants tab of the Initial Assessment – Primary page. The spelling of a child's name can be modified on the child's Person Management page.

[TM6]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Birth Date field on the Basic tab of the child's Person Management page.

[TM7]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Add/Edit button and selectthe desired Parental Role(s) from the list of Case Participants on the Participants tab of the Initial Assessment – Primary page. The spelling of a parent's name can be modified on the parent's Person Management page.

[TM8]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Birth Date field on the Basic tab of the parental's Person Management page.

[TM9]This field is pre-filled.

This field is not editable on the template.

This field will pre-fill from the Initial Face-to-Face Documented field on the Assessment page. The data can only be corrected on the existing case note if the note has not been finalized. If the field does not pre-fill, a new case note must be created. The case note must have a Category of “Initl Assess Contact” and Type of “Initial Face-to-Face Contact."

[TM10]This field is pre-filled.

This field is not editable on the template.

This field will pre-fill from the Initial Face-to-Face Documented field on the Assessment page. The data can only be corrected on the existing case note if the note has not been finalized. If the field does not pre-fill, a new case note must be created. The case note must have a Category of “Initl Assess Contact” and Type of “Initial Face-to-Face Contact."

[TM11]This field is pre-filled.

This field is not editable on the template.

This field will pre-fill from the Initial Face-to-Face Documented field on the Assessment page. The data can only be corrected on the existing case note if the note has not been finalized. If the field does not pre-fill, a new case note must be created. The case note must have a Category of “Initl Assess Contact” and Type of “Initial Face-to-Face Contact."

[TM12]This field is pre-filled.

This field is not editable on the template.

The data can only be corrected on the existing case note if the note has not been finalized. The contacts can be added/deleted on the Assessment contact note in the Assessment Contact Information group box before the note is finalized. If the Participant (Contacts) does not pre-fill, a new case note must be created. The case note must have a Category of “Initl Assess Contact” and a Type of “Face-to-Face Contact" or “Initial Face-to-Face Contact."

[TM13]This field is pre-filled.

This field is not editable on the template.

The Note Type data cannot be corrected on the existing case note.

[TM14]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: update the "Face-to-Face Location" field on the existing case note if the note has not been finalized.

[TM15]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: update the "Face-to-Face Result" field on the existing case note if the note has not been finalized.

[TM16]This field is pre-filled.

This field is not editable on the template.

The Case Note ID data cannot be corrected.

[TM17]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the ‘Presenting CPS Issue’ field on the Presenting Issues tab of the Initial Assessment – Primary page.

[TM18]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: The checkbox can be updated by selecting the Yes or No radio button for the 'One or both parents/caregivers intend(ed) to hurt the child' field on the Maltreatment tab of the Initial Assessment – Primary page.

[TM19]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: The checkbox can be updated by selecting the Yes or No radio button for the'Living arrangements seriously endanger the physical health of the child' field on the Maltreatment tab of the Initial Assessment – Primary page.

[TM20]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows:1The Child Name pre-fills from the Child Name field on the ChildFnctng tab of the Initial Assessment – Primary page and can be updated in the on the Basic tab of the child’s Person Managementpage.

[TM21]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: 1Update the ‘Describe the child’s general functioning and effects of any maltreatment’ field on the ChildFnctng tab of the Initial Assessment – Primary page.

[TM22]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: The checkbox can be updated by selecting the Yes or No radio button for the 'The child is profoundly fearful of home situation or people within the home.' field on the AdultFnctng tab of the Initial Assessment – Primary page.

[TM23]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows:1The Parental Role Name pre-fills from the Parental Role Name field on the AdultFnctng tab of the Initial Assessment – Primary page and can be updated on the Basic tab of the adult's Person Managementpage.

[TM24]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the ‘Describe the adult's general functioning, daily life management ...’ field on the AdultFnctng tab of the Initial Assessment – Primary page.

[TM25]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Yes or No radio button for the 'One or both parents’ / caregivers’ behavior is dangerously impulsive or they will not / cannot control their behavior' field on the AdultFnctng tab of the Initial Assessment – Primary page.

[TM26]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Yes or No radio button for the 'One or both parents/caregivers are violent' field on the AdultFnctng tab of the Initial Assessment – Primary page.

[TM27]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows:1The Parental Role Name pre-fills from the Parental Role Name field on the ParentalPractices tab of the Initial Assessment – Primary page and can be updated on the Basic tab of the adult's Person Managementpage.

[TM28]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: 1The Description can be updated in the ‘Describe the disciplinary approaches generally used by the parent and the typical context within which they are used’ field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM29]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: 1Update the ‘Describe the parent's general parenting practices (nurturing, limit setting, protectiveness, provision of basic care, etc.)’ field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM30]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Yes or No radio button for the 'Child has exceptional needs which parents/caregivers cannot/will not meet' field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM31]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Yes or No radio button for the 'No adult in the home will perform parental duties and responsibilities' field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM32]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Yes or No radio button for the 'One or both parents/caregivers fear they will maltreat child and/or request placement' field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM33]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Yes or No radio button for the 'One or both parents / caregivers lack parenting knowledge, skills or motivation necessary to assure the child’s basic needs are met.' field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM34]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Yes or No radio button for the 'One or both parents / caregivers have extremely negative perceptions of the child. ' field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM35]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Yes or No radio button for the 'Family does not have or use resources necessary to assure the child’s basic needs.' field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM36]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: The narrative can be updated in the ‘Describe the family's general functioning, strengths, and current stresses..' field on the ParentalPractices tab of the Initial Assessment – Primary page.

[TM37]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the Yes radio button forthe 'One or more factors that negatively affect safety are identified' field on the Risk and Safety tab of the Initial Assessment – Primary page.

[TM38]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Select the No radio button forthe 'One or more factors that negatively affect safety are identified' field on the Risk and Safety tab of the Initial Assessment – Primary page.

[TM39]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows:1The Date of Safety Assessment field is pre-filled from the Date of Safety Assessment field on the Risk and Safety tab of the Initial Assessment-Primary page and can be updated in the Date of Safety Assessment field on the Safety Assessment tab of the associated Safety Assessment and Plan page.

[TM40]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: The assignment of Alleged Victim role can be changed on the Roles page accessed on Participants tab of the Assessment page.

[TM41]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the 'Relationship to Victim' field on the Allegations tab of the Assessment page.

[TM42]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the 'A/N Code' field on the Allegations tab of the Assessment page.