Update Psychosocial Evaluation Report Instructions

SAFE Update Report

Update

Psychosocial Evaluation Report Instructions

If no changes have occurred since the last Update/Home Study Report leave the language in the Update Report Section and move onto the next Psychosocial Evaluation Section. If there have been changes delete the paragraph under the appropriate section and follow the directions below. Please note that initial or continued placement of children into the Applicant's home must be addressed in the Update Report under "Children Placed in the Home".

If the Final Updated SAFE Desk Guide Rating is a 3, 4, or 5 provide a narrative that includes the following:

What issue/behavior or event warranted the SAFE Desk Guide Rating of 3, 4 or 5? State what the issue/behavior or event is/was.

Describe the societal, personal, cultural and/or family dynamic that contributed to or set the stage for the issue/behavior or event.

Describe the frequency and severity or intensity of the issue/behavior or event.

Describe how the issue/behavior or event influenced the Applicant’s ability to function, both in the past and currently and how it effects children in the home.

REMEMBER: All mitigation that Sustains, Reduces or Erases a Final SAFE Desk Guide Rating must include supporting evidence or documentation – facts, observations, analyses, and/or examples.

Sustaining: If an issue/behavior or event is not resolved and you are sustaining the SAFE Desk Guide Rating, please indicate how it affects the Applicant’s current functioning, ability to parent and how it would or does affect children in the home.

Reducing: If an issue/behavior or event is partially resolved and you are reducing the SAFE Desk Guide Rating, please provide evidence that indicates how the issue/behavior or event was reduced, how it would or does affect current functioning, ability to parent and how it would or does affect children in the home.

Erasing: If you believe that an issue/behavior or event no longer affects the Applicant and you are erasing the SAFE Desk Guide Rating, please provide evidence to support your assessment that the issue/behavior or event no longer affects the Applicant’s current functioning or ability to parent.

*please electronically delete this page before printing the final home study report

All paragraphs bracketed with [ ] are directions and should be deleted

SAFE Update Report

Completed by: / Name of Caseworker/Evaluator:
Name of Agency
Street Address
City, State, ZIP Code
Person #1: Applicant 1 Full Name
Home Phone: / Mobile Phone:
E-Mail:
Address:
State/Province: / Zip/Postal Code:

< Update Purpose

Approved for Adoption On: Date
Purpose of Update:

SAFE Update Report

DATES OF CONTACT

Date

Person(s) Interviewed

Length of Interview

Location

< Children Placed in Home

First Name, Last Initial / Relationship / Placement Status
☐ No children placed into the home

< Others Residing or Frequently in the Home

Name / Age / Relationship / Current Situation
☐ Only Applicant Resides in Home

> MEDICAL REPORTS

Medical Reports

Health Evaluation from [--name--] pertaining to Applicant 1 Full Name dated:
Health Evaluation from [--name--] pertaining to [--name--] dated:
Health Evaluation from [--name--] pertaining to [--name--] dated:

UPDATED CRIMINAL/CHILD PROTECTIVE SERVICES RECORDS CHECK

The required criminal record and child abuse/neglect checks were completed for Applicant 1 Full Name along with any adult(s) living in the Applicant’s home. Any findings will be elaborated on in the Psychosocial Evaluation History section of this report.
<CNAF> <CNAM> <CNAL> has disclosed that he/she has resided in the following state and countries since age 18: [--List states and countries--]
Applicant 1 Full Name / State Criminal Records Clearance / [--date & findings either cleared or not cleared--]
FBI Criminal Check / [--date & findings either cleared or not cleared--]
DMV/SOS Records Check / [--date & findings either cleared or not cleared--]
Child Protective Records Check / [--date & findings either cleared or not cleared--]
Other: / [--date & findings either cleared or not cleared--]
Other Adult / State Criminal Records Clearance / [--date & findings either cleared or not cleared--]
FBI Criminal Check / [--date & findings either cleared or not cleared--]
DMV/SOS Records Check / [--date & findings either cleared or not cleared--]
Child Protective Records Check / [--date & findings either cleared or not cleared--]
Other: / [--date & findings either cleared or not cleared--]
Other Adult / State Criminal Records Clearance / [--date & findings either cleared or not cleared--]
FBI Criminal Check / [--date & findings either cleared or not cleared--]
DMV/SOS Records Check / [--date & findings either cleared or not cleared--]
Child Protective Records Check / [--date & findings either cleared or not cleared--]
Other: / [--date & findings either cleared or not cleared--]
Other Adult / State Criminal Records Clearance / [--date & findings either cleared or not cleared--]
FBI Criminal Check / [--date & findings either cleared or not cleared--]
DMV/SOS Records Check / [--date & findings either cleared or not cleared--]
Child Protective Records Check / [--date & findings either cleared or not cleared--]
Other: / [--date & findings either cleared or not cleared--]

> SELF STATEMENT OF Applicant 1 Full Name

The applicant was asked the following questions on [--date--] and the answer to each question is below.

1. Do you have a criminal history in the United States or abroad, even if it did not result in an arrest or conviction?

2. Do you have a history of substance abuse, whether in the United States or abroad, even if such history did not result in an arrest or conviction?

3. Do you have a history of sexual or child abuse as an offender or victim, whether in the United States or abroad, even if such history did not result in an arrest or conviction?

4. Do you have a history of domestic or family violence, as an offender or victim, whether in the United States or abroad, even if such history did not result in an arrest or conviction?

5. Have you ever been rejected as a prospective adoptive parent or have you ever been the subject of an unfavorable home study?

6. Have you previously had a home study completed, or began the home study process in relation to an adoption (domestic or inter-country) or any form of foster or other custodial care, whether or not it was completed?

> SELF STATEMENT OF Adult Household Member(s) (If Applicable)

[--Delete this section if there are no other adult household members and label N/A--]

The Adult Household Member was asked the following questions on [--date--] and the answer to each question is below.

1. Do you have a criminal history in the United States or abroad, even if it did not result in an arrest or conviction?

2. Do you have a history of substance abuse, whether in the United States or abroad, even if such history did not result in an arrest or conviction?

3. Do you have a history of sexual or child abuse as an offender or victim, whether in the United States or abroad, even if such history did not result in an arrest or conviction?

4. Do you have a history of domestic or family violence, as an offender or victim, whether in the United States or abroad, even if such history did not result in an arrest or conviction?

5. Have you ever been rejected as a prospective adoptive parent or have you ever been the subject of an unfavorable home study?

> MOTIVATION

[--State the Applicant’s stated reasons for wanting to adopt internationally. Specify their country of choice and why they have chosen this country. --]

Psychosocial Evaluation Report

> History: Applicant 1 Full Name

For the period of this review there were no allegations of abuse or neglect involving [Applicant 1].

[--Narration Instructions: If the sentence above is incorrect, delete it and fully narrate the nature of the allegations and disposition.--]

Since the last evaluation nothing has been reported, detected or observed that resulted in the revision of any of the most current determinations for this section. Their current history does not contain any issues, behaviors or events that were not addressed in the original or subsequent evaluations.

Mental Health Reports

Referrals were not made to mental health resources as the practitioner’s professional assessment that none were needed based on the Applicants’ current functioning and the fact that they did not have any significant issues related to any past history of illness, or any mental, emotional, psychological, or behavioral instability.

[--If referrals were made to mental health resources for further mental health evaluation during the update period, indicate the evaluation conclusions and specific issues that required further evaluation using Psychosocial Narration Instructions (page 1)--]

> Personal Characteristics: Applicant 1 Full Name

Since the last evaluation nothing has been reported, detected or observed that resulted in the revision of any of the most current determinations for this section. Their personal characteristics do not contain any issues, behaviors or events that were not addressed in the original or subsequent evaluations.

> Marriage Relationship

During the report period there has been no change in the marital status of the Applicant.

Since the last evaluation nothing has been reported, detected or observed that resulted in the revision of any of the most current determinations for this section. Their current relationship does not contain any issues, behaviors or events that were not addressed in the original or subsequent evaluations.

> Sons/Daughters/Others Residing or Frequently In the Home

Minor Son(s)/or Daughter(s)

☐ There are no minor sons or daughters in this family.

Since the last evaluation nothing has been reported, detected or observed that resulted in the revision of any of the most current determinations for this section.

[--Narration Instructions: If one of the statements above is correct, delete these narration instructions. If the statement is incorrect, delete it and provide the minor’s name, date of birth and gender followed by a description of their personality, interests, school and living situation. During the reporting period has the minor’s behavior been age-appropriate? Has the minor presented any health, developmental, educational or mental health issues? How secure, well-adjusted and adaptable has the minor been? Have his/her needs been well met? Has the minor exhibited behaviors that pose a threat to the health, safety and well-being of self or others? Does the minor have a secure attachment to both his/her/parents? Have any alcohol or drug involvement occurred? How has the minor responded to the arrival or anticipated arrival of a new child(ren) into the family?--]

Other Minors Residing or Frequently In the Home

☐ There are no minors residing or frequently in the Home (Note: Foster children placed in the home or children placed in pre-adoptive status are not included here.)

Since the last evaluation nothing has been reported, detected or observed that resulted in the revision of any of the most current determinations for this section.

[--Narration Instructions: If one of the statements above is correct, delete these narration instructions. If the statement is incorrect, delete it and provide the minor’s name, date of birth and gender followed by a description of their personality, interests, school and living situation. Is the minor’s behavior age-appropriate? During the reporting period has the minor’s behavior been age-appropriate? Has the minor presented any health, developmental, educational or mental health issues? How secure, well-adjusted and adaptable has the minor been? Have his/her needs been well met? Has the minor exhibited behaviors that pose a threat to the health, safety and well-being of self or others? Does the minor have a secure attachment to both his/her/parents? Has any alcohol or drug involvement occurred? How has the minor responded to the arrival of a new child(ren) into the family?--]

Adult Son(s) or Daughter(s)

There are no adult sons and daughters in this family.

Since the last evaluation nothing has been reported, detected or observed that resulted in the revision of any of the most current determinations for this section.

[--Narration Instructions: If one of the statements above is correct, delete these narration instructions. If the statement is incorrect, delete it and provide the name, date of birth, gender and marital status of each adult identified. Indicate each individual’s occupation, circumstances and the amount and type of contact they have had with any child(ren) placed in the home. During the reporting period how positive and supportive have they been about a new child or children coming into the family? How much and how frequently have they consumed alcohol? Have they used illegal drugs or abused prescriptive/over-the-counter drugs? How well have they accepted differences? Have they exhibited responsible behavior and emotional stability? Have they exhibited any behavior that posed a threat to the health, safety and well-being of themselves or others? Have there been any criminal arrests, convictions or allegations of child sexual/physical abuse, child neglect, child exploitation or failure to protect during the reporting period?--]

Adults Residing or Frequently In the Home

There are no other adults living or frequently in the home. (Note: The definition of adults frequently in the home is any adult who is in the home on a regular basis and has substantial contact with children placed in the home or any adult who while in the home would have access to be alone with children placed in the home.)

Since the last evaluation nothing has been reported, detected or observed that resulted in the revision of any of the most current determinations for this section.

[-If one of the statements above is correct, delete the narration instructions that follow. If the statement is incorrect, delete it and use one of the two following narration instructions that applies:

For an adult living or frequently in the home who has been assessed during previous evaluations, provide the name of the adult and any changes in their situation or amount and type of contact they have had with any children placed in the home. During the reporting period: How positive and supportive have they been about a new child or children coming into the family? How much and how frequently have they consumed alcohol? Have they used illegal drugs or abused prescriptive/over-the-counter drugs? How well have they accepted differences? Have they exhibited responsible behavior and emotional stability? Have they exhibited any behavior that posed a threat to the health, safety and well-being of themselves or others? Have there been any criminal arrests, convictions or allegations of child sexual/physical abuse, child neglect, child exploitation or failure to protect during the reporting period?