initial foster/adoption home evaluationdhhs.michigan.gov/.../webhelp_pro/adoption/week3/... ·...

BCAL-3130 (Rev. 9-14) Previous edition obsolete. MS Word 1

INITIAL FOSTER/ADOPTION HOME EVALUATION Michigan Department of Human Services

Bureau of Children and Adult Licensing

Applicant(s) interested in:

Relative Assessment.

If yes, please describe legal relationship: You should also check the adoption box for relatives

Foster Care

Adoption

AGENCY NAME:

AGENCY LICENSE NUMBER: Date of Report: Revised 10-14 KMS

1. FOSTER/RELATIVE/ADOPTIVE HOME INFORMATION:

Home name:

Please note that spell check does not always work automatically on this document!!! You

can use it by going to the Review tab and selecting spelling and grammar.

Put the names of all applicants for adoption here.

Foster home license number, (CF # or CG#): For adoption purposes, we will not have this number

Address:

Home telephone number: Other telephone number (s):

Email address:

Driver’s license number/State ID number for all adult members of the household; verification of valid driver’s license:

Be sure to put the name of the person, the driver's license # and how you verified this

information for all household members who have a driver's license. Note if there is a

copy of it in the file and the date it expires.

Also, note if the address is the same on the BCAL 3130 as it is on the driver's license.

They need to update their address if they have not yet done so.

MEMBERS OF HOUSEHOLD:

Name DOB Relationship to Caregiver

Date of Placement (if applicable)

List everyone here, including the

Applicants listed above

DIRECTIONS TO THE HOME:

SOCIAL WORK CONTACTS:

Date Persons Type of Contact/Place

”Click Here and Type” Here you need to show that you had face to

face contact with all members of the

household.


You also want to demonstrate that you

contacted the family within 7 days of them

deciding to adopt the child or of your

receiving the referral if the child was

matched at that time.

You must show monthly contact with the

applicants in this section.

There must be a clear on-site walk through

of the home indicated here.

All the rest of your contacts must go here

2. BCAL CLEARANCES: For all Adult Members of the Household: Act 116, R.400.9201, R.400.9202, R.400.9205, R.400.9206)

A. Date of BCAL Criminal History Check for everyone 18 years and older: Results of Criminal History Check: See Policy ADM 520 for what clearance requirements are.

Fingerprints, BCAL and CPS checks, ICHAT or LEINS and local clearances all go here

with names of individuals checked and dates they were completed. LEIN’s cannot be

summarized as per policy and should not be reffered to as LEIN’s in the report.

We do not need BCAL's written approval for adoption purposes but you may need to

consult with MCI office.

Criminal History exists for named offense, PLACEMENT IS PROHIBITED if a member of the household has a

felony conviction for the following crime(s):

1. Child abuse/neglect.

2. Spousal Abuse.

3. Crime against children (including pornography).

4. A crime involving violence, including rape, sexual assault or homicide but not including other physical assault or

battery. 5. A physical assault or battery within the last five years.

6. A drug related offense within the last five years.

Please explain: This policy is different for adoption than it is for foster care.

Criminal History exists but does not prohibit placement. List all offenses. Describe the length of time since the

offense and the services completed that rectified the situation. Address safety risks and identify protective interventions. Assess rehabilitation:

As stated above.

The CPA must have the written approval of BCAL to recommend original licensure if there are any pending criminal charges.

B. CENTRAL REGISTRY:

Michigan Date of Central Registry Check: Has applicant lived in any other states in the

last 5 years? Yes No If yes, identify what states the person lived in. There must be a central registry clearance from that state. See policy ADM 520 for help with this.


The confidentiality of information in this section of this document is protected by the Michigan Child Protection Law. Anyone who violates this protection is guilty of a misdemeanor and is civilly liable for damages (1975 PA 238, as amended, MCL 722.621 et seq.).

Central Registry Results:

N/A: Not found

Yes, there is a history of child abuse or neglect.

a. Describe the length of time since the substantiation and any services that have been provided to rectify the

concern.

b. Address any risk factors that might impact the safety of the child and describe what protective interventions

are in place currently.

*If there is any household member who is on Central Registry, THE HOME CANNOT BE LICENSED.

Are there any rules that are in non-compliance? Yes No

If Yes, list all rules and headings:

Willful Substantial

Supporting documentation: ART: Yes No

3. COMMUNITY:

Type of community (rural, urban, etc.):

Make sure you ask the person these questions and don't just use census data. We want a

picture of the community from the family's perspective and not just data.

You will describe if the community is in a rural- country setting, an urban - city

setting or suburban type setting.

Socio-economic makeup:

Include the entire community and be clear if there are areas of lower, middle or upper

class or a combination of any of them nearby.

Racial/cultural makeup:

Again, make this mostly based on what the family's awareness is of the racial and

cultural makeup of their community. You can also indicate if you know the racial make-up

of the schools a child will attend.

Availability of recreational facilities:

Describe the recreational facilities in the area and what is available for children. Be

sure to clarify the rec facilities that they use and not just the ones in the area since

sometimes there are facilities available but the family would never use them.

School system, including special education:

List the names of the public schools in the area, list the distance from the home, list

any private schools if the family intends to send their children there or already does,

be sure to mention special education services for all schools and how you confirmed the

services are there; it is also acceptable to address any special services that schools

have to offer for special needs children or extracurricular programs for students.

Hospitals and medical care, noting facility utilized by family:

How close is the nearest hospital, where would an ambulance take a person, where is the


nearest urgent care facility?

Where does the family go for medical care in the area? Identify who takes Medicaid in the

area.

You can also include if there is access to any special medical services if the family is

requesting to adopt a medically fragile child.

Availability of churches, noting family’s choice of church:

List all the types of religious facilities that are availible in the community noting the

family's choice for where they attend and if they are open to take a child to other

places.

4. DESCRIPTION OF HOME: (R.400.9206, R.400.9301, R.400.9302, R.400.9303, R.400.9304, R.400.9305, R.400.9306,

R.400.9307, R.400.9308, R.400.9309, R.400.9401, R.400.9410, R.400.9411, R.400.9414, R.400.9418, R.400.9419)

Description of home and all rooms, noting condition, layout, and appearance: (Does the home meet the minimum level of cleanliness necessary to meet the needs of the child to be placed? If not, is the applicant taking action to address the home’s deficiencies?)

Describe the home as in type like a bungalow or two story, etc.

Describe the layout of the home as if you are walking through it and include if it is

wheelchair accessible.

Condition will include what the home looks like, are appliances working, any needed

maintenance of home and appearance refers to cleanliness of home, and if the home is

cluttered or neat, etc.

Do a FULL walk through of the home and outside of the home.

Explain if the home is appropriate and if not, address what will be done to get it up to

standards for adoption purposes.

Description of play space:

Indoors and outdoors and appropriateness of it for different ages. Is it safe? Are they

located on a busy street? Is the backyard/front yard fenced in?

Safety considerations, including weapons or pets:

Are there pets in the home? Yes No Does the pet have current vaccinations? Yes No

Is the pet friendly or is the pet a safety concern? (Explain what makes the pet a friendly or a safety concern. Describe how does the pet interacts with others.)

Indoor dogs and cats need to be vaccinated. Dogs need to be licensed if they are four

or more months old per the Michigan Dog Law. Be sure to check the City Ordinance for

pets in the community they live in. Barn cats that do NOT go indoors would not need

vaccinations.

Be sure to explain any exotic animals/pets (anything beyond a cat or dog) that the

family has and address any risk that they might pose to children in the home.

Also note who takes care of the animals.

Be sure to observe how the animal interacts with others. Bring a co-worker if you

have a fear or allergy to the pets.

Is the pet well cared for? Yes No

Are there any water hazards on or near the premises? Yes No If yes, describe how the caregiver plans to

safeguard children around them. Any exterior door that leads directly to the area where there is a water hazard needs an alarm. Any pool, spa, hot tub or pond needs rescue equipment available.

Be clear as to the rules of the household and how they are enforced with regards to


any water on the premises. Make sure all household members are aware of the rules.

Licensing require alarms on back doors that lead to water hazards. For adoption

purposes, we may allow them to adopt without them, but possibly not when small

children live in the home. Also, locked gates around swimming pools.

Are there working smoke detectors on each floor and between each sleeping area and the rest of the home? Yes No

Is there a working carbon monoxide detector installed as recommended by the manufacturer? Yes No

Be sure that smoke detectors all work and are in proper locations.

If the family does not have a carbon monoxide detector, often you can obtain one for

free from a local fire department.

If there are weapons in the home, specify what they are, where they are stored and how they are secured. Document all weapons (rifles, handguns, bow and arrows, air/paint guns, etc.), registrations, trigger locks/inoperable and storage. Weapons must be inoperable and locked in a place separate from ammunition or stored in a locked gun safe.

Guns need to be stored in a locked location and they need to be trigger locked or

inoperable. Ammunition needs to be stored in a separate locked location. Any

handguns need to be registered and the certificate should be viewed by the worker and

probably a copy kept in the file. Also, the worker needs to view that all weapons are

stored safely, not just ask the question. Please also don't forget that cross bows or

swords or other types of weapons would also want to be kept locked away from children.

If the adoptive parents (or any adult household members) have a concealed weapons

permit, they need to show it to you and also still be aware that they may not carry a

weapon on them in the home per our policies.

Where are medications stored?

You can address if prescription medication is stored properly and used properly, but

if the doctor prescribes it to them, they are allowed to have it. You can have a

doctor write a letter addressing if they are physically capable of parenting if a

medication concerns you. Remember that licensing requirements include locking all

medications up and document if you are not making such requirement and why not.

Explain the proposed sleeping arrangements for family members and foster/adoptive children.

Here is where you need to state the size of the mattresses that they sleep on and who is

in which room. If a room may be used in the future for a bedroom but is not being used

now, you need to note if they have a mattress and frame for the room and what size it is

or where they will obtain one. Is there a CPSC compliant crib if there are children under the age of 2 or the home is to be licensed for children 0-2?

They will need to have this if they are requesting to adopt only children under the age

of 2. If are requesting a larger age range, then address if they are aware of what it

means and can obtain the crib if matched to a child under the age of 2.

Do all bedrooms have a window and a door than can be used to get out of the house in an emergency? Yes No

If “NO”, please explain:

Use of basements requires egress windows or windows that are large enough for a person to

escape from.

Are there people sleeping in other rooms in the home? Please describe.

People can only be sleeping in other rooms if there is adequate space and exits for


emergencies. Describe if there is any reason someone is sleeping in a “non bedroom” and

the safety of the situation.

Water, sewer, refuse arrangements, health inspection results if applicable:

Don't forget to include if garbage is picked up at the curb or if it has to be paid to be

picked up.

If they have a well, you need to include the inspection results and the date of

inspection - BCAL pays for this for licensing purposes but you have to ask them if they

will cover it for adoption only purposes. If they don't, you may be able to use NRE from

subsidy to cover this expense.

Water temperature tested 120

o Fahrenheit or less? Yes No

You need to carry a thermometer and test the hot water coming out of the faucet. Meat

thermometers or candy thermometers work well for this. Best practice is to test multiple

faucets in the home (sometimes the one closest to the water heater is hotter). The

temperature must be under 120 or you will need to come back and test it again on another

day until it is correct.

Emergency procedures information completed and posted in view of the home telephone:

Tornado, fire and medical emergency procedures discussed AND the family is all aware of

the plans. Licensing has a form that you can use if you wish or you can develop one in

your office. Licensing requires it to be posted in the home, but we just require that it

exists and that everyone is aware of it. Feel free to suggest it to be posted.

Adequacy of the house, property, neighborhood, schools and community for the purpose of fostering/adopting as determined by on-site visits:

You need to actually view the house, property, out buildings (such as garages, sheds,

etc.), neighborhood, schools and community. There has to be a statement that says that

you found each of them to be adequate or more than adequate for the purposes of adopting

as determined by an on-site visit on X date. Be sure you are really assessing all that

is asked of you here.

Means of transportation; i.e. ages and makes of automobiles, reliability, proof of insurance on each vehicle, availability of required safety seats for young children, accessibility of public transportation if needed:

Does a bus route lead to their home, can they call a taxicab

List out the cars they have and what they use for transportation and include proof of

insurance for each vehicle. Probably a good idea to check the tags too!

DESCRIBE PLANS FOR DAY CARE AND/OR SUBSTITUTE CARE. (R400.9403(d)(ix), R400.9412)

Here is where you would include who will take care of the child in the event of an

illness or death of the adoptive parents. Also any babysitters or other help the family

has.

Routine Day Care:

Here is where the daycare information belongs as well as what will happen if the child

cannnot attend daycare that day due to a fever or illness. Include if their work is

flexible to them needing time off to parent or to working from home.


After hours and emergency substitute care:

Describe if there is a need for any after-hours daycare and how this will be met or what

the family’s plans are for emergency needs.

Don’t forget to address this for stay at home caregivers. Just because there is a stay

at home parent in the family does not mean that they will not ever need substitute care.



Willful Substantial

Supporting documentation:

Variance requested? Yes No 5. FINANCIAL: (R.400.9201, R.400.9206)

Date family provided with information of Ineligible Grantee Funds, Medicaid, Food Stamps, WIC in DHS-Pub-114 for children in relative care:

This would be foster care's responsibility, but we can make sure it was done. For our

children who are MCI Wards, the relatives will get State Ward Board and Care Funds.

Source of income, how this was verified, stability of income, how expenses were verified. Does the family have a plan for

any known financial changes that may occur in the future i.e., unemployment payments ending, cash assistance ending?

You need to view their bills - see copies of their mortgage payments, cable/internet

bills, water bills, electric/gas bills, phone bills, credit card bills, car payments,

etc. You want to account for what they pay in grocery bills and for clothing and

recreation etc. You may also discuss the cost of any hobbies they have or activities

they pay for like sports for the children. You may also have to discuss any money they

set aside or use for activies such as gambling or purchasing cigarettes.

If income is based on disability, i.e. SSI, Social Security Disability, long term disability payments from a job, workmen’s

compensation, etc., describe the verification of the physical or mental disability and an assessment of how that impacts the ability to provide foster/adoptive care or be a member of the household.

If child support payments are ordered, are the payments being made and are they current? If there are arrears, how much

and what is the plan to bring the payments current? How was this verified?

You need to check with Friend of the Court if they have court ordered child support

payments and confirm that they are up to date with all payments.

Detail a financial statement that specifies the amount of net income for the household and identifies all ongoing and

routine bills and expenses including, but not limited to, housing (mortgage or rent, insurance, property taxes), utilities, food, clothing, transportation (car payments, insurance, fuel), credit cards, student loans, contributions to religious organizations, savings contributions, etc.

This would be a good time to ask the family if they have any history in filing for

bankruptcy and get the story behind the circumstances and impact on credit.

Assess the family’s money management skills and ability to meet their needs with their current income. Is the family

current on their bills? Can the family meet the financial expenses of having a relative/foster child placed in their home prior to payment starting?

You need to make a clear statement that they are financially stable for the purposes of

adoption. Be clear that their debt to income ratio was considered. They just need to be

able to make monthly payments on large amounts of debt - not have enough to pay it off

today.




Willful Substantial


Variance? Yes No 6. SOCIAL HISTORY: (for each adult member of the household, including adult children who live in the home) (R.400.9201,

R.400.9202, R.400.9206)

Descriptive information: Age, height, weight, hair color, nationality, race or ethnicity, place of birth. American Indian heritage must be consistent with information on the BCAL-3889 and the BCAL-0120-A. Family of origin description. Include:

Number of siblings, parents’ roles, personalities, expectations, parenting involvement, styles, values.

Relationship with each parent and siblings (if any) growing up and now.

Parents’/primary caretakers’ childrearing techniques, including discipline.

How family dealt with losses. Describe family celebrations.

Parents’ substance use and how it affected the family, lasting impact on individual.

How family dealt with any abuse or victimization issues, continuing impact on individual.

Role of religion in the family.

Other significant influences when a child, e.g. grandparents, step parents, aunts, uncles.

Be sure to address this for each adult member of the household.

Be very clear and write specifics of what is requested - use the words they use above.

For example, the mother's role was to be a stay at home mom and do the housekeeping while

the father's role was to go to work daily and do the outside chores. Values and

expectations may be similar (i.e., a parent valued honesty and expected their children to

be honest), but should still be listed separately.

Clearly explain parents expectations - did they expect you to attend college, go to

church, be a good student, spend time with family, etc.

Parenting styles tend to be things like - she was a very relaxed and easy going in her

parenting style; he was a strict disciplinarian in his parenting style; etc.

Parenting values can vary greatly from home to home - her parents valued education,

family and good moral character; his parents valued religion and attending church; their

parents valued spending time with family and having fun together; etc.

Don't forget to cover relationships with parent and siblings growing up and now

Include the discipline used in their birth home. Specify if one parent was different

than another or if anyone other than their parents also provided discipline.

Address losses in the family and how they dealt with it. This does not just mean death;

it can refer to loss of a job, loss of a home due to fire, loss due to divorce, loss due

to a natural disaster and any other types of loss they had in their life. Don’t just say

“they grieved,” but describe their grief process.

Describe family celebrations - why they celebrated, who came, how often, holidays, etc.

Note is asks for substance use, not just abuse. Be sure to include substance abuse even

if there is a lack of it. There could also be a lasting impact if the parents rarely or

never used substances, even if that lasting impact is merely that the individual uses


their parents’ behavior as a reference for what they consider to be acceptable substance

use.

Be sure to address abuse or victimization history even if it was not an issue in the

home. It is generally best to state that “applicant denies a history of abuse or

victimization,” rather than stating, “There was no abuse or vicitmization in applicant’s

home,” as the latter is stated as a fact, while the former indicates that the absence of

abuse or victimization is the applicant’s self-report.

Describe if the family was religious. How often they participated in services and how

religion played a role in their childhood.

Describe any other persons who were influencial in their life such as a close grandmother

or aunt, fictive kin, teachers or coaches, etc.

Any history of out of home care? This should include any history in non-court-ordered out of home care.

Educational history and any special skills and interests:

Employment history – If the person does not have an employment history or there are large gaps in the employment history, explain how they were supported during that period of time:

Relationship history – Significant relationships prior to current one; how they ended; if previously married, whether divorce has been obtained or considered and whether there is verification.

Be sure to mention any history of out of home care - even if it wasn't foster care

related. Again, if they say there was no out-of-home care, state that “applicant denies

any history of out-of-home care…”

Explain if they have a high school diploma or a GED and where they attended school.

Describe any higher education they obtained, where, when, what, etc. Address the special

skills and interests while in school, such as special skills that help with obtaining a

job. Later on you will address hobbies and interests not educationally related.

Employment history, you don't have to include every little job they had when they were

younger. Just important, relevant employment history. Mostly professional stuff.

Explain if there are any gaps in employment and why or a lack thereof.

Include ALL previous significant relationships - especially if any children were born

from that relationship. Just give brief descriptions of how long they dated, why they

broke up, any children from the relationship, any dv incidences, and other important

details.

Any children from previous relationships. Yes No Note any history of involvement in domestic violence, including as a victim, or absence of history:

Be clear to note an absence of any domestic violence history. This is another place where

you should use “applicant denies a history of domestic violence…” if they say it has

never been an issue.

Description of personality, personal goals, hobbies, interests

As explained, cover each of the required points above.

Strengths and weaknesses, worker’s assessment in addition to what the applicant tells you:

Be sure that you assess their individual strengths and weaknesses in addition to what

they tell you - don't just agree with what they say. Also, do not assess them as a

couple if they are married or involved; you must assess each applicant individually.




Willful Substantial


7. FAMILY LIFE: (R.400.9201, R.400.9202, R.400.9206, R.400.9405, R.400.9418)

Marital and family status and history, including current and past level of family functioning and relationships and any incidents of domestic violence:

Current relationship. Include:

Brief history, including date and place of marriage, if applicable.

Any history of infertility and how that has been dealt with.

Any history of separations or domestic violence.

Strengths of relationship, areas of work or attention.

Common/shared interests or lack thereof.

Roles, division of labor, decision-making process, handling stress or disagreements.

Assess level of satisfaction, stability.

Describe relationship w/parent of children if separated.

Be sure to address current and past level of family functioning for all families

including a statement if there is any history of domestic violence and how they get

along relationship wise now.

Then use this section only if they are in a current relationship and address each

point that is requested of you. Be sure to note all previous marriages and divorce

as well as current one and list that documentation is on file with your agency for

each of them. Note if they have grown from experiences of divorces or multiple

marriages or if it is a recurring pattern for them.

Be sure to note an absence of infetility issues if there are none. Same with

domestic violence. Unless you have documentation of infertility, separations, or

DV, use “applicant denies…” if they say it has not been an issue. Family:

Activities, goals, values, role of religion, church involvement:

This is where you address a lot of the similar questions asked in social history,

but now you are answering them for this family's current status.

Be specific to answer each thing asked here.

Challenges, stressors, any history of help-seeking:

Be sure to address what the family feels is any challenges they have as well as any

stressors they deal with in the past or currently. Also, any current or past

history of seeking outside assistance in managing stress or challenges such as a

therapist.

Losses and how dealt with:

It is important to address how the family deals with loss, as the child they adopt

will need assistance in managing losses in their life. Loss is not just death, it

can be loss of a job, divorce, moving, infertility, etc. Address all types and how

they dealt with them.

Expected impact of fostering/adopting on all members of the household:


How will adopting a child from the foster care system impact each member of the

family has the household as a whole?

Any individuals other than children of applicants currently living with the family, impact of those individuals on family functioning.

Address any individuals living in the home (i.e., grandma, a family friend, etc.),

other than the children of the applicants, and the impact of the other person

living in the home on the family’s functioning. An example here would be to

describe if the grandmother living in the home needs any care from the applicants

that may detract from the care of the children or if grandma is able to assist with

care of the children.

8. CHILDREN: (R.400.9201, R.400.9202, R.400.9206, R.400.9404, R.400.9407)

All children must be interviewed/observed apart from the parents, even adult children no longer living in the home, or the agency must note all attempts to contact them. If unsuccessful, the applicant’s explanations as to why you were unable to contact them.

For each child living in the home including relatives/foster children:

Identifiers: name, birth date, race (if different from parents’) school and grade, and/or employment. Date of placement for children already placed in the home (relatives).

Parents’ description of child’s personality, interests, activities.

General adjustment, note if any involvement with law enforcement or the criminal justice system.

Worker’s assessment of child’s adjustment, development, special needs, relationships with parents and their significant others, and other strengths and weaknesses.

Child’s ideas and attitudes about fostering/adopting based on interview with the child.

Child’s description of the discipline techniques used in the family.

Be sure to interview each child ALONE - unless they are really young. Give it a

try even with young children just to be sure there isn't anything they need to tell

you away from their parents.

Answer each statement listed above and note in this section what you ask the

parents, what you assess on your own from gathering information and what you ask

the child directly.

For children who are grown and/or out of the home: Identifiers: name, age, where living, marital status.

School and/or employment.

General adjustment: note if any problems with law enforcement or the criminal justice system.

Their opinion of their parents’ parenting skills and of their desire to foster/adopt children.

Description of the discipline techniques used when they were a child.

The willingness of the adult child to provide substitute care, if appropriate, or be involved with the foster/adopted children who may be placed into the home.

Any ongoing reliance by the adult child on the applicant for child care, monetary assistance, etc.

Adult children not living in the home need to be included in this section. You can

refer to a DHS 611 Adult Child Reference or interview them directly. Be sure to

address each statement listed above.



Willful Substantial


Variance? Yes No


9. HEALTH: (For each member of the household, both adult and children): (R.400.9201, R.400.9202, R.400.9206)

Assessment of physical, mental and emotional health and substance use history.

Address each member of the household's current and previous physical, mental and

emotional health. Note they are asking substance use history and not just abuse.

If the person is prescribed any psychotropic medications, they will need a additional

letter from their doctor stating their diagnosis, what they are prescribed, how long they

have been on their medication and if they are stable in their treatment. Licensing has a

great form you can use for this information if you so choose.

Indicate current health status. (Is anyone in the household prescribed medication? If so, list the medications. How long has he/she been taking these medications/what are the medications prescribed to treat?)

You can have a doctor write a letter addressing if they are physically capable of

parenting if a medication concerns you.

Does anyone in the household have a physical or mental health diagnosis or condition that would make care of the child difficult? If so, describe how it may affect the care of a child.

Just answer question as stated.

Describe current substance use patterns, history if indicated. If there is a past substance use problem (including alcohol use) indicate how diagnosed, resolved, and when. What is the current treatment?

Describe any substance use in the home and if it has ever been an issue or become a

problem.

You can't deny someone for smoking, but you can require them to smoke outdoors or not

around the child if it is for a medical reason such as asthma.

Be sure to address any previous substance abuse here.

Does any member of the household smoke? Yes No If yes, do they smoke in the house? Yes No Reference a medical statement, completed within the 12 month period before conclusion of the evaluation, for each

member of the household that indicated that the member has no known condition which would affect the care of a foster/adoptive child or any other determination if different. Does anyone require special care? Please describe:

Each household member needs a physical completed within one year of completion of the

adoption (some counties want it sooner). This needs to be updated if it expires. It

needs to be on a DHS 3190 and you may want the family to get the second page completed

even if the form doesn't require that. Find out what your court requirements are.



Willful Substantial


Variance requested? Yes No 10. PARENTING: (R.400.9201, R.400.9206, R.400.9306, R.400.9401, R.400.9403, R.400.9404, R.400.9417)

Parenting skills and attitudes toward children:

Address parenting skills and general attitude towards children and how you know they have

them. Include any observations as to this. Parenting values:


Most important things for parents to do, what they will do similarly to their parents, what they hope to improve upon.

Do not skip parenting values because it is above the other statement! Describe the

things they value in parenting such as the things they were taught to value and will they

want their children to learn the same.

Discuss the things they believe are most important for parents to do.

Explain what they want to do similar to their parents and what they will want to do

differently.

Be specific if they were spanked and describe what they will do different than spanking.

Knowledge of child development, appropriateness of expectations of children.

Be clear as to their knowledge of child development and how they actually obtained this

knowledge. Include any experience they have or interactions they have had with all ages

of children.

Be sure to be thorough and find out if they understand how to appropriately adjust their

expectations for different children based on their needs and development.

Ability to provide infant care:

Equipment, safety measures in place (e.g. gates, monitor, car seat, play area, pets)

Make sure you include a statement here if they are not requesting to adopt an infant that

you are not assessing them for this at this time so they will not be approved for an

infant in their home

If they are requesting an infant or a toddler, address safety equipment locations and if

they have it already or need to purchase it and how they will get it when needed.

Safe Sleeping requirements have been trained and reviewed

Be sure to include the date you reviewed this information with them.

Understanding of infant care:

Again, address if they are requesting to adopt an infant or toddler and if they are, do

they understand proper care of an infant. How do you know they understand and what

experience have they had with an infant?

Capacity and disposition to give a foster child guidance, love and affection and to deal with difficult children with

unacceptable behavior, children who are rejecting and/or oppositional, or children with medical needs.

Very important to include a statement as to their capacity and disposition to provide an

adoptive child with guidance, love and affection. Include a description of how the

family shows affection to one another.

Next address their ability to deal with difficult children as explained above. Be sure

to not only address difficult behavior, but include rejecting and oppostional behavior as

well. Then be sure to include a statement as to whether or not they can meet the needs

of a child with medical needs and possibly explain to what level of needs they are

capable of working with.


1. What kinds of behaviors require intervention?

Have the family describe what types of behaviors they would intervene for - hurting self

or others, etc. Unless the family only plans on intervening for one type behavior, there

should be more than one type of behavior here.

2. How will caregiver intervene/handle that type of behavior? How will they be supportive and nurture children?

What types of intervention are they open to - would they seek outside help and for what?

How will they be supportive and nuture children? So provide examples they give as to how

they feel they can show support and nuture a child.

Methods of discipline. Flexibility and age appropriateness of approaches, willingness to follow the case plan for the child if it differs from their normal approach to discipline.

Explain their discipline techniques and all that is asked here. It is important that

they understand not to spank foster and adopted children or to use any physical

discipline or inappropriate discipline styles at all.

Explain if/how they are flexible and age appropriate in their discipline styles.

Be clear as to their willingness to follow the case plan for the child if it differs from

their normal approach to discipline.

Awareness of variety of techniques, use of positive and negative methods.

Does not mean good/bad, but rather positive as in positive reinforcement for good

behaviors and negative as in responding after the behavior has already occurred.

Understanding of agency’s discipline policy and willingness to abide by it. If the family has used spanking or other

corporal punishment, or was raised with it, document their current attitudes.

Be sure to thoroughly account for any ideas about spanking and understanding why we do

NOT spank foster and adopted children.



Willful Substantial


11. MOTIVATION FOR FOSTER CARE/ADOPTION: (R.400.9201, R.400.9202, R.400.9206, R.400.9403, R.400.9404,

R.400.9405, R.400.9411)

Reasons for wanting to provide care for relative/foster/adoptive children, including infertility, if indicated.

Be sure their motivation is appropriate and that they have dealt with all infertility

issues.

Each member’s attitude towards accepting a relative/foster/adoptive child.

This would be in regards to an adopted child for our purposes.

Previous experience in providing child foster care, child day care, or adult foster care.

All previous experience goes here.

Previous adoptive evaluations or placements.

Have they been studied for adoption by any other agencies and what were the

recommendations of those assessments? Did they result in placements or not and why?


Previous licenses, including applications that did not result in a license. Reference communication with previous agency.

Any requests for licenses goes here - previous and current. If they were previously

licensed but their license has since been closed, explain the circumstances. You may

have to obtain additional information from BCAL or their previous agency to address this

in order to ensure that there were not concerns which lead to the agency’s refusal to

keep the family’s license open.

Level of understanding of foster/adoptive care and the potential impact of their family. For example, does the caregiver understand that a social worker will visit the child and relative at least monthly until reunification with parents occurs or permanent custody is achieved?

Family does need to understand foster care to adopt a child from the system and will need

to be able explain to the child about termination of parental rights, etc.

Evaluation of motivators, (if adoption/relative placement in particular).

It is possible for someone's motivation to not be appropriate so be sure to really

discuss this.

Applicant(s) agree to encourage visits and follow health care, religious and discipline policies of this agency

Even for adoption, it is important for them to follow agency policy.



Willful Substantial


12. FAMILY’S ATTITUDES TOWARD THE CHILDREN’S PARENTS AND WORKING WITH THE AGENCY: (R.400.9201,

R.400.9202, R.400.9206, R.400.9403)

Understanding of permanency and concurrent planning.

Basically just address that the family is applying to adopt and is prepared for

permanency and if they will be involved in any concurrent planning - (most likely not on

the adoption end)

Family’s level of understanding of foster/adoption care.

Family does need to understand foster care to adopt a child from the system and will need

to explain to the child about termination of parental rights etc.

Family’s willingness to comply with the child’s case plan. If child is in the home, assess current situation.

The family is willing to cooperate with the supervising agency.

The family is willing to cooperate with the school system.

The family is willing to cooperate with the child’s therapist.

The family is willing to cooperate with the parenting time plan outlined in the treatment plan.

The caregiver is willing and able to protect the child(ren) from further harm.

Address the adoption specific ones from this list.

Attitudes toward the legal parents. How will foster parents discuss legal parents with and around foster/adoptive children?

Still important on the adoption end to make sure they have appropriate attitudes towards

birth parents and will express them appropriately to the children.

How will foster parents discuss reasons children entered foster care and/or became available for adoption?


Again, still important as an adoptive parent…

Family understands the goal of the agency in providing foster care and they are willing to support the agency in working toward reuniting a foster child with his or her family.

This would not apply for adoption purposes and you can state this.

For Relative Placements:

Does the family agree to not release the child to anyone, including birth parents, without the supervising agency’s

approval? Yes No

Does the family agree they will not allow the foster child(ren)’s parents to live in their home without the supervising

agency’s approval? Yes No

Does the family understand they cannot be licensed to care for foster children whose parents live in the home?

Yes No Ability to empathize and work with the parents and children.

Just address their ability to work with birth families, siblings and children. Some

cases you may want to discuss openness to birth parent contact if it is appropriate.

Openness to maintaining significant relationships.

All birth family relationships as well as maybe former foster parents or teachers or

coaches, etc.

Openness to providing permanency to the relative/foster child if needed.

For adoption, you would just put that they have applied to adopt and this has already

been determined.

Ability to comply with agency policies and procedures.

Assess according to your agencies policies and procedures

Summarize experience of caseworkers for children who have been placed in the home. Assess current compliance.

This would not apply for adoption unless the person was licensed or had a relative placed

in their home.



Willful Substantial


13. TRAINING NEEDS: A statement of the number of hours the person/couple need to comply with the training rules is not

sufficient. (R.400.9415)

Orientation and training hours credited; include topics covered.

State the date thay they completed orientation and that they completed 12 hours of PRIDE

training including the dates that they receieved sessions 1, 2, 3, 4 & 6. Also include

the topics covered in those sessions.

They need to have completed training before you can approve them for adoption.

Types of training the family believes they could benefit from.

Ask the family their needs and help them find what trainings on the topics they are

interested in.


Worker’s assessment of additional training needs and the agency’s plan to provide the identified training.

Be sure to add how the family will obtain any training you recommend.

Openness to learning.

Assess how open they are to learning more and how eager they are to get more information.

Also be sure to ask any trainers they've had if they actually partipate and learned from

their PRIDE training.



Willful Substantial


Variance requested? Yes No 14. TYPE OF CHILDREN DESIRED – INTEREST IN PERMANENCY/ADOPTION PLANNING: (R.400.9201, R.400.9202)

Gender, race, ethnic background and special characteristics of children preferred by applicants.

Types of children the family is willing to consider.

This is just information on the type of child the family prefers – be sure to include

number of children, age range, sex, race and ethnic background, and then describe

characteristics.

Special characteristics: think MARE standards - none, mild, moderate, severe - physical,

educational, emotional, medical, etc. at a minimum!!! Ideally, this would include

specific behaviors or diagnoses.

Be sure to differentiate between what the family prefers and what they might be willing

to consider. Maybe they prefer a 4 year old female but are open to up to age 8 male or

female as an example.

Ability and willingness to care for special needs children, and the problems of the children.

Also, state what the family would not be able to manage in a child

Interest in adoption.

Clearly they would be interested in adoption for our purposes so just state this.

If this evaluation is being completed for an adoption of a specific child, the DHS 612, Adoptive Family Assessment Addendum, must be completed.

You can state if the family is already matched to a specific child here and then just

state that the 612 will be completed as required. You can also state the family is not

yet matched to a specific child and the 612 will be completed only when this occurs or

other circumstances make it necessary.

15. CROSS CULTURAL PLACEMENT:

Willingness to parent cross-racially or cross culturally and to create an atmosphere that fosters racial identity and culture of a foster child.

Are they willing is the key to this - not do you think they can handle other races -

remember MEPA training when you ask these questions.

Races or cultures requested or that the family does not believe they can effectively parent.

Just what the family states they can or cannot handle - not what your opinion is!


16. REFERENCES: (R.400.9206)

At least three references must be obtained from persons not related to the applicant(s).

State who gave the references and what their relationship is to the applications. Be

sure to note if anyone refuses to provide a reference and reasons why if they gave any.

Summarize the information received from each reference. If negative information was received, explain how the negative information was resolved.

Summarize references without stating who said what - for example, one reference said this

and another reference reported that.

An agency may choose to obtain additional references from related or unrelated persons, including adult children.

Put adult child references (using the adult child reference form) and any other

references that the agency chooses to obtain (employer, pastor, etc.) here.

If this is an adoption assessment and there are circumstances that require additional review, include the information provided by the professional reference.

Use the professional reference form and do not use foster care workers or licensing

workers for this type of reference.

See policy ADM 510

17. RECOMMENDATIONS: (Must be consistent with the information contained in the report.)

Placement with relative is recommended: Yes No If the recommendation is that placement should not be made, the reason for this must be explained in detail.

Licensure is recommended: (Licensing workers only)

Yes No N/A

Licensure and preliminary approval for adoption: (Licensing workers only)

Yes No

Approved for adoption: (Adoption workers only)

Yes No

Summary of strengths and areas of growth, attention.

Summarize the main points here - the family's strengths, areas they can improve or grow,

etc. Issues to be considered in making placements

Be specific if there are things to consider specific to a family - do they have pets,

young children, no handicap access, issues with others living in the home, they need

subsidy for financial support, etc. Recommended placement specifications to include characteristics, age, sex, and number of children best served by

home and types of children who may not be placed in the home.

Be specific as to what you are recommending placement wise for this family but you do not

need to name a child - that is done on the DHS 612 Addendum.

Also address the types of child you would not recommend for this family. These might

include children who display particular behaviors or diagnoses that the family said they

were not willing to parent, as well as children who have needs which you have assessed


the family as not being able to meet at this time. Be specific regarding

behaviors/needs/diagnoses which the family is not willing or able to parent.

Recommendation for License Denial:

N/A List all rules found to be in non-compliance.

Summarize facts to support rule non-compliance.

Reference all supporting documentation.

Recommendation for Adoption Denial:

List any reasons you are denying a family here… Basis for recommendation:

Supporting documentation.

18. CLOSING:

Licensing/Adoption Assessment Submitted by: Don't forget to run an ICHAT or LEIN on any

unlicensed adults in the household before you approve

this report! Name:

Signature:

Agency:

Title:

Date: I certify that I have been trained and am qualified to make this recommendation:

Foster Care Adoption 19. SUPERVISOR’S REVIEW:

Application: Talk to the supervisor about how they want you to handle this section.

Usually you include the dates of all the documents. Clearances: Include names of people as well as dates when appropriate. Medical Reports: References: Other documentation: Is the report accurate, factually consistent, unbiased, support by adequate data/information? Yes No

Further Explanation: Once a supervisor checks yes and signs this, it is approved and complete.

Supervisor Name:

Signature:

Agency:

Title:

Date: I certify that I have been trained and am qualified to make this recommendation.


Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.

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