MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILREN'S DIVISION FAMILY FUNCTION ASSESSMENT/RE-ASSESSMENT	CD-14A
FAMILY INFORMATION ASSESSMENT DATE:
CASE NAME	COUNTY	CASE NUMBER
WORKER NAME	WORKER NUMBER	SUPERVISOR
MINIMUM CONTACT STANDARD (Monthly Contacts based on the most recent SDM Level of Risk)
Very High--3 face to face contacts, at least 2 by the worker----3 collateral contacts High---------2 face to face contacts, at least 1 by the worker----3 collateral contacts Moderate---1 face to face worker contact-----2 collateral contacts Low----------1 face to face worker contact-----1 collateral contact
FAMILY FUNCTIONING
Rate each sub-factor listed below and check the phrase (clear strength, moderate strength, adequate, moderate need or serious need) that most accurately describes the family’s level of functioning in the present situation. Historical items, particularly for re-assessments will continue to exist, however the way they impact family functioning may change significantly. Describe specifics in the appropriate column below as either clear or moderate strengths or serious or moderate needs. Clear or moderate strengths should be utilized to address serious or moderate needs in the CD-14B Written Service Agreement.
BASIC NEEDS
What is the impact of basic needs on Family Functioning?
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Food/Nutrition (quantity, quality)
Finances (debt, income, management)
Clothing (appropriate, adequate)
Transportation (Public or private--available, reliable)
Childcare (type---available, reliable, appropriate)
Housing Type--housing situation (e.g., homeless, in temporary shelter, with relative/friend, in own apartment or house)
Housing Stability--relative permanency of housing (e.g., current threat of eviction, family is current on rent/mortgage, family has been in the same residence for one year or more).
Habitability of Housing--adequacy and appropriateness of the family’s living environment (e.g., space for family members, furnishing, physical/structural condition, functional utilities, privacy for family members, status of housekeeping).
Health/Sanitary Living Conditions (presence or absence of dirt, animal feces, moldy food/ dishes, dirty cloths, clutter, vermin infestation)
Other
Clear or Moderate Strength	Serious or Moderate Need

CAREGIVER ABILITY
How does the caregiver’s ability impact family functioning?
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Parent/Caretaker Attachment ( exhibited attachment to children)
Protection from Outside Threat (example: protection from abusive spouse or paramour, baby proofing, storage of weapons or drugs)
Provides Safe Environment (Example: weapons access, exposed wiring, broken glass, meth lab)
Supervision (consider age, vulnerability, length of time alone)
Learning Environment (Hinders or promotes healthy development, example: books, writing or drawing material, learning toys—Age appropriate toys/games)
Knowledge of Child Development (statements or behavior that demonstrate knowledge of child development)
Expectations of the Child (realistic or unrealistic in regard to child’s age or physical mental or social capability)
Behavior management (caretakers effectiveness of managing the behavior of the children)
Discipline (effectiveness/appropriateness of discipline)
Care/Feeding/Nutrition (caretaker’s behavior which demonstrates care and feeding, nutritional quality of food)
Caretaker’s special needs that affects quality of childcare (disabilities, number of children, health problems, substance addictions)
Child’s special needs that affects quality of childcare (disabilities, severe behaviors, medical problems)
Other
Clear or Moderate Strength	Serious or Moderate Need

EDUCATIONAL/VOCATIONAL
How does Educational/Vocational success/failure, for the caregiver or the child, impact family functioning?
Child-Educational/Vocational
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Educational/training
Career goals
Other
Clear or Moderate Strength	Serious or Moderate Need
Caretaker-Educational/Vocational
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current Employment/or unemployed
Educational level/training
Employment history
Career goals
Support of child(ren) educational goals
Other
Clear or Moderate Strength	Serious or Moderate Need
PHYSICAL HEALTH
How does physical health and level of health care impact family functioning?
Child-Physical Health
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current physical health
History of significant physical/dental health conditions
Sight/Hearing impairment
Clear or Moderate Strength	Serious or Moderate Need
Caretaker-Physical Health
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current physical/dental health
Sight/Hearing impairment
History of significant physical/dental health conditions
Willingness/Capacity to address special health needs
Practice of preventive care (regular check-ups, health/nutrition/dental habits; sight/hearing exams)
Caretaker’s health education/knowledge
Other
Clear or Moderate Strength	Serious or Moderate Need
MENTAL HEALTH
How does mental health and level of health care impact family functioning?
Child-Mental Health
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current mental health
History of significant mental health conditions
Other
Clear or Moderate Strength	Serious or Moderate Need
Caretaker-Mental Health
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current mental health
History of significant mental health conditions
Willingness/capacity to address special health needs
Caretaker’s mental health education/knowledge
Other
Clear or Moderate Strength	Serious or Moderate Need

SUBSTANCE USE
How does the caretaker or child’s use of substances impact family functioning?
Child-Substance Use
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current use of substances (frequency, amount)
Substance history-(includes prior use/abuse, treatment or whether the child was drug exposed as an infant)
Problems related to substance use. (may include: Family/peer relationships, social, school, legal, financial or family violence)
Other
Clear or Moderate Strength	Serious or Moderate Need
Caretaker-Substance Use
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current use of substances (frequency, amount)
Caretaker’s substance history—includes prior use/abuse, treatment
Problems related to substance use. (may include: marital, parental, social, legal, financial or family violence)
History of/or currently using during pregnancy
Drug related incarceration/legal issues (Current, Hx)
Other
Clear or Moderate Strength	Serious or Moderate Need Substance(s) of concern
FAMILY INTERACTION
How do healthy or harmful interactions between family members impact family functioning?
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Adult/Adult Interaction (conflict resolution, communication, support)
Custodial/Non-custodial parents (ongoing relationship between divorced or estranged parents)
Adult/Child Interaction (conflict resolution, communication, support)
Child/Sibling Interaction (conflict resolution, communication, support)
Child/Peer Interaction (quality and amount of peer interaction, Hx of conflict)
Family Attachment (expression of support, concern, communication between family members)
Domestic Violence History (in current relationship or prior relationships)
CA/N History (Division history or reported by family)
Other
Clear or Moderate Strength	Serious or Moderate Need
CRIMINAL/LEGAL ISSUES
How does the caretaker’s or child(ren)’s criminal/legal issues(or lack of), impact family functioning?
Child-Criminal/Legal
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current juvenile/legal system (convictions, detention, court supervision)
Past juvenile/legal system (convictions, detention, court supervision)
Nature of criminal issues (violent or sexual crimes/child abuse/theft//illegal substances/status offenses)
Other
Clear or Moderate Strength	Serious or Moderate Need
Caretaker-Criminal/Legal
Sub-factor	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Current criminal/legal status (Incarceration, probation/parole, outstanding warrants)
Past criminal/legal issues (convictions, Incarceration, probation/parole)
Nature of criminal issues (violent or sexual crimes/child abuse/domestic violence/illegal substances)
Other
Clear or Moderate Strength	Serious or Moderate Need

CHILD WELL-BEING
Rate each of the five components of child-wellbeing (physical, emotional, behavioral, relationships and educational) as they affect family functioning as a whole. Be child specific in regard to exhibiting behaviors/symptoms.
Child Physical Well-being How does physical health affect day to day functioning? Consider positive and negative consequences.	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Check all that Apply	Name of child(ren) exhibiting behavior/symptoms
Current health problems
Chronic health problems
Physical disabilities
Other
Child Emotional Well-being How does emotional health affect day to day functioning? Consider positive and negative consequences.	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Check all that Apply	Name of child(ren) exhibiting behavior/symptoms
Sleep disturbance
Eating disorder
Enuresis/encopresis
Depressed/withdrawn
Anxious/fearful
Suicidal
Other

Child Behavior How does behavior affect day to day functioning? Consider positive and negative consequences.	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Check all that Apply	Name of child(ren) exhibiting behavior/symptoms
Short attention span
Safety/protection ( behavior presents safety risk or ability to protect self)
Physical disabilities
Aggressive/destructive
Run away
Inappropriate Sexual behaviors
Substance abuse
Other
Child’s Relationships (Health of the child’s relationships/ability to engage in relationships, pattern of relationships)	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Check all that Apply	Name of child(ren) exhibiting behavior/symptoms
Poor relationship with caretaker
Attachment Issues
Poor peer relationships
Poor sibling relationships
Other

Child Educational Well-being (relationship with school, school involvement, social/academic success…etc.)	Clear Strength	Moderate Strength	Adequate	Moderate Need	Serious Need
Check all that Apply	Name of child(ren) exhibiting behavior/symptoms
Learning disabilities
Poor school attendance/phobia
Retained a Grade
School Phobia
Lack of Connection with School
History of Truancy
No Participation in Extracurricular activities
Other
How does over all Child Well-being affect family functioning as a whole?
Clear or Moderate Strength	Serious or Moderate Need

ATTACHMENTS/UPDATES
CD-14 FCS Family Assessment (Only for initial assessment) has been reviewed/approved by supervisor. CD-17 Safety Assessment (if appropriate) CD-18 Safety Plan (if required) CD-14E Risk Assessment (Only if not completed previously) CS-16E Risk Re-Assessment (Every 90 days) CD-14B Written Service Agreement or last page of the CS-1 for FCOOHC (Unless a decision to close has been made) Update CD-14C Formal/Informal Provider Contact Sheet (Add new formal/informal provider contacts) CD-14D Termination of Services/After Care Plan (For Case Closings only) Other Next Reassessment Due Date
I hereby certify that all family assessment and case planning activities documented and evaluated in the CD-14 (initial assessments) and CD-14A, in cooperation with the family, did occur and are in my best professional judgment an accurate assessment of this family’s strengths and service needs.
Worker:	Date:
Supervisor’s Comments/Recommendations:
I hereby certify that I have reviewed the CD-14 (initial assessment) and the CD-14A and all attached documents; have provided ongoing consultation during the case assessment and case plan process; and am in agreement with the assessment and result of this document.
Supervisor:	Date: