MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION FCS FAMILY ASSESSMENT
FAMILY INFORMATION
INITIAL CONTACT CASE PRIORITY: Low (Within 10 working days) Moderate (Within 5 working days) High/Very High (Within 1 working Day)
CASE NAME	COUNTY	CASE NUMBER
ADDRESS	TELEPHONE NUMBER
DIRECTIONS TO THE ABOVE ADDRESS
WORKER NAME	WORKER NUMBER	SUPERVISOR
CASE ASSIGN DATE	ASSESS BEGIN DATE
PARENTS
MOTHER’S NAME CUSTODIAL NON-CUSTODIAL	DOB
ADDRESS (IF DIFFERENT FROM ABOVE)	DCN	TELEPHONE NUMBER
FATHER’S NAME CUSTODIAL NON-CUSTODIAL	DOB
ADDRESS (IF DIFFERENT FROM ABOVE)	DCN	TELEPHONE NUMBER
CHILDREN
NAME	DOB	DCN	NAME	DOB	DCN
List children with American Indian Heritage. Specify Tribe.
OTHER HOUSEHOLD MEMBERS/SIGNIFICANT OTHERS
NAME	DCN	RELATIONSHIP	ADDRESS/PHONE
/
/
/
/
SUMMARIZE HISTORY WITH AGENCY
REASON FOR CD INVOLVEMENT
FAMILY’S PERCEPTION OF CD INVOLVEMENT
MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION Safety Assessment	Case Name:	Safety Threshold Criteria
Case/Call Number:	specific observable	out of control	likely serious harm	present or near future
Date completed:
Participant being assessed:	Children involved:
Safety Factor Identification: Based on an analysis of the identified threat of danger to each vulnerable child and the caregiver’s capacity to keep the child safe check “unsafe” when the household conditions meet the Safety Threshold Criteria
Child(ren) is in danger because parent/caregiver’s behavior is violent or out of control.	Safe Unsafe
List Vulnerable Children:
Parent/caregiver describes or acts toward child(ren) in predominantly negative terms or has extremely unrealistic expectations.	Safe Unsafe
List Vulnerable Children:
Parent/caregiver caused serious physical harm to the child(ren) or has made a plausible threat to cause serious physical harm.	Safe Unsafe
List Vulnerable Children:
The parent/caregiver’s explanation of an injury to a child(ren) is inconsistent with the nature of the injury and/or there are significant discrepancies between explanations given by parent/caregiver, other household members, or collateral contacts.	Safe Unsafe
List Vulnerable Children:
Parent/caregiver is currently refusing access to child(ren) or has refused access to child(ren) on prior interventions.	Safe Unsafe
List Vulnerable Children:
Parent/caregiver has not, will not, or is unable to provide supervision necessary to protect child(ren) from potentially serious harm. If “yes,” is the parent/caregiver’s lack of supervision due to:	Safe Unsafe
Parent/caretaker’s physical, mental health or cognitive incapacity	Child’s physical, mental health or cognitive incapacity
Alcohol or other drug use	Hospitalization	Incarceration
Domestic Violence	Other
List Vulnerable Children:
Parent/caregiver is unwilling, or is unable, to meet the child(ren)'s imminent needs for food, clothing, shelter, and/or medical or mental health care. If “yes,” are the child(ren)’s basic needs unmet by the parent/caregiver due to:	Safe Unsafe
Parent/caretaker’s physical, mental health or cognitive incapacity	Child’s physical, mental health or cognitive incapacity
Alcohol or other drug use	Hospitalization	Incarceration
Domestic Violence	Other
List Vulnerable Children:
Child(ren) is fearful of parent/caregiver, other family members, or other people living in or having access to the home.	Safe Unsafe
List Vulnerable Children:
The child(ren)'s physical living conditions are hazardous and immediately threatening.	Safe Unsafe
List Vulnerable Children:
Child(ren) sexual abuse is suspected and circumstances suggest that child(ren) safety may be an immediate concern.	Safe Unsafe
List Vulnerable Children:
The parent/caregiver’s maltreatment history is significant to the current circumstances, and suggest that the child(ren)’s safety is an immediate concern.	Safe Unsafe
List Vulnerable Children:
Safety Decision:	Safe (no safety factors were checked)	Unsafe - CD-18 Safety Plan is required. (One or more threats of danger were identified) Absent prevention services/safety intervention, out-of-home placement would likely be the planned arrangement for the child.
Worker’s Signature	Date	Supervisor/Chief Investigator Signature	Date
Supervisor/Chief Investigator Review:	Approved Request New Safety Assessment
Comments:
IMPORTANT: If the Safety Decision is “unsafe”, complete and attach CD-18 Safety Plan.

GENOGRAM DATE: Diagram at least three generations. (Example: children, parents and grandparents); Questions 1 through 3 should be addressed in the body of the genogram. Question 4 should be answered at the bottom.
1. Are there any significant positive or negative generational trends or patterns of behavior? (example: current reason for involvement, presence or absence of divorce, alcoholism, career success, domestic violence, strong extended family, presence or absence of physical or sexual abuse, positive or negative role models…etc.) 2. What relatives are seen as available for support or assistance? (example: resource for childcare, financial assistance, shelter, temporary placement resource…etc.) 3. What relatives are seen as negative/harmful to the well being of the subject family? (example: custody issues, history of conflict or victimization…etc.) 4. Who might be included in an FST for family support? (List below, including name, phone and address) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ECOMAP DATE: (Label surrounding circles with significant social systems for the family. (Examples: recreation; faith/cultural; social/community; court system, housing; healthcare; employment; school/education; extended family; friends or other sources for family support not named.) Questions 1 and 2 should be addressed in the body of the ecomap. Question 3 should be answered at the bottom.
Family/Household Fill in connections where they exist. Indicate nature of connections with a description word or by drawing two different kinds of lines: --------------------for strong- - - - - - - - - for tenuous and \/\/\/\/\/\/\/\/\ for stressful. Draw along lines to signify flow of energy, resources, etc.
1. Who in the family’s environment is seen as available for support or assistance? 2. Who in the family’s environment is seen as inaccessible/ negative or harmful? 3. Who might be included in an FST for family support, not listed on the previous page? (List below, including name, phone and address) _________________________________________________________________________________________________________

PATTERN OF BEHAVIOR (optional) Use the pattern developed with the family to develop their Written Service Agreement ( CD-14B). (See example below) Items in shaded box represent possible changes to the pattern which can be listed as goals for the family on the plan for change.
Child refuses Father yells at mother to clean house Mother feels guilty and picks up child’s toys Child plays with toys Child leaves the toys out Mother asks child to pick up toys Ask Mother’s Aunt Sally for advice Father asks daughter to pick up her toys Family discussion in regard to consequences for child’s behavior Mother leaves the room and counts to 10 when she feels like hitting Mother asks father to intervene when she feels like hitting Mother slaps child Parents will understand their own abuse through counseling in order to use non-abusive discipline with their child. Only let her play with toys in her room EXAMPLE
Pattern of Behavior Date: