ADT Concurrent CPS/DV Assessment CPS Assessment Section 1: Child/Youth Assessment (Complete for each child) Intake ID: Case: (Case Name) Individual: Interview Interview Refused to be interviewed Unable to be interviewed Native American No Unknown Yes Declined to disclose Child Physical/Mental Health (check all that apply) Risk Factors Hearing or vision impaired History of seizures Medical diagnosis requiring life sustaining measure Medical diagnosis requiring ongoing care Medical issues (asthma, broken arm, severe allergy) Mental health diagnosis ongoing medications Physical disability Requires psychotropic meds to function No Risk Factors Protective Factors No physical/mental health issues Received care for identified mental health issues Receives care for identified medical issues Up to date on immunizations
Intake ID: Case: (Case Name) Individual: Interview Interview Native American Refused to be interviewed Unable to be interviewed No Unknown Yes Declined to disclose Adult Health and Functioning Risk Factors Alcohol abuse Attention seeking Dishonest and/or manipulative Disregard for others’ safety or wellbeing Drug abuse Hostile to authority figures or service providers Impulsive or unpredictable Intellectual or cognitive disability Irrational or disconnected from reality Lacks insight into their own behavior Mental health issue that affects functioning Paranoid Physical disability or debilitating illness Selfish, self-centered decision-making Unable to apply logic to solve problems Unable to assess (due to inability to interview) No Risk Factors Protective Factors Accepts assistance that enhances functioning Candid and/or cooperative Copes or functions despite a disability Demonstrates logic/reasoning ability No mental health issues No physical health issues Primary relationships are stable Realistic awareness of self and reality Respects the rights and feeling or others Seeks and give affection to loved ones Ability to Manage Daily Life and Stress (High Risk Behaviors) Risk Factors Abuses substances (drugs/alcohol to escape or deal Protective Factors College or career training
Attitude Toward Caretaking Risk Factors Articulates inappropriate expectations for child Caretaker self-reports may harm child Describes child in negative terms Doesn’t follow through with required medical treatment Fails to protect child Fails to supervise child Frustrated by parenting duties Inability to recognize situational risks to child Not attached to the child Puts personal needs before child Unable to assess (due to inability to interview) Uses poor judgment in choosing caregivers No Risk Factors Protective Factors Attached to the child Demonstrates cooperation with child’s service providers Has realistic expectations of child Meets child’s needs Parent seeks and follows medical advice Prioritizes the child’s safety Receives satisfaction being a parent Recognizes dangerous situations CPS/APS/Criminal History Risk Factors Adult is registered sex offender Parental rights on a child involuntarily terminated Prior convictions involving drugs/alcohol Criminal “versatility”: variety of types of convictions Prior felony convictions involving weapon/violence Prior revocation of parole/probation Prior substantiated reports Prior substantiation death/near death of another child Action or lack of action contributed to death/serious harm of a child Multiple prior reports not accepted for investigation Prior unsubstantiated reports No Risk Factors Protective Factors Acknowledges responsibility for prior charges Acknowledges responsibility for child welfare allegations No criminal charges No felony convictions No prior CPS/APS history Non-violent/traffic offenses Other rehabilitative services Received treatment/rehabilitative services related to prior sexual abuse
Notes Section 4: Family Functioning Family Functioning (INTAKE) Case: (Case Name) Individual: Is the home a health or safety hazard for the individuals living there? Broken windows Dangerous animals in the home Dangerous chemicals accessible Exposed wiring Fire safety hazards Hoarding Holes in floor or walls Human/animal feces Inadequate heat in winter Infestation of rodents/insects Inoperable sanitation Insufficient shelter (includes homeless) Medications not secure Meth lab Mold infestation Spoiled food Unsafe space heaters Unsupervised with loaded guns/weapons No issues What corrective action has caretaker made for any checked item?
Investigative Related Data Report received: Assigned by Supervisor: Inv Worker Received Report: First Attempt to Make Contact: First Face to Face Contact Made with Victim Date: First Face to Face Contact Made with Victim Time: First FSOS Consultation: mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy mm/dd/yyyy Roles of Individuals Interviewed Alleged Perpetrator Alleged Victim Attorney Clergy Custodial Parent Day Care Provider Employer EMS/Fire Department Former Spouse Family Friend Family Support/Kames Forensic Consultation Household Member-Related Household Member Non-Related Landlord Law Enforcement Medical Provider Mental Health Provider Neighbor Non-Custodial Parent Paramour/Partner Relative School Personnel No collateral contact Spouse No collateral contact
Risk Factors Adult has an intellectual or behavioral disability Adult is fearful of alleged perpetrator Adult reports pain Adult sees no need for a safety plan and is unwilling to implement it Blames self for abuse Explanation of injury is not consistent with the facts Financially dependent Imprisoned/confined to the home Isolation Multiple injuries present Ongoing violence/threats of harm Substance abuse Unable or unwilling to access needed services/resources Past supports/services no longer available (effective) Protective Factors Able and/or willing to access needed services resources Access to finances Adult demonstrates ability to protect self Adult is not fearful of alleged perpetrator Adult reports no pain Children/others can assist with safety Has independent transportation Identified supports to assist with safety Minor injury to non-critical part of body/no medical treatment required No evidence of sexual abuse present No physical evidence of injury Recognizes the need for safety plan and is willing to implement it Spouse Abuse Notes Section 2: Injuries The Victim has: Observable injury Internal injury Mental injury Complaint of pain No injury No injury but allegation occurred Injury was caused by being