Exhibit H Clinical Family Assessment rev 10-23-15.doc

EXHIBIT H

State of Arizona

Department of Child Safety

Office of Procurement

3003 N. Central St, 20th Fl.

Phoenix, AZ 85012

CLINICAL FAMILY ASSESSMENT

Case Name:

Date of Assessment:

Family Composition: (List Last, First names and dates of birth)

a. General Physical Description (height, weight, hair/eye color, skin tone/ethnicity, outstanding features, scars, tattoos, etc.):

b. Family Background (Mother, Father, siblings, include cultural influences):

c. Education/Occupation/ Military History and Current Status:

d. Religious Background Preference:

e. Health History and Current Status:

f. Support Systems:

g. Marital History and Current Status:

h. Criminal History and Current Status:

i. Domestic Violence History and Current Status:

j. Substance Use and Abuse History:

k. History of Psychological and/or Psychiatric Treatment:

l. Description of past and Current Problems Relating to Family and Abuse/Neglect:

m. Parenting: (Describe the degree of knowledge and application of current parenting style and problems):

n. Parent/Child Interactions: (Dates/Duration of Observations):

o. Recommendations to include Placement, Visitation and Services:

INFORMATION BELOW TO BE OBTAINED ONLY AS REQUESTED BY DCS CASE MANAGER.

Child Composition: (List Last, First name and date of birth of child)

a. Age appropriate physical, mental and emotional development.

b. Impact of family dysfunction on child.

c. Evidence of manipulating or coaching child in custody disputes.

d. Child’s perception of family crisis/functioning.

e. Child’s fears and/or feelings of security

f. Progress in school and ability to concentrate.

g. Recommendations for more intensive evaluation, services or intervention.

Submitted by: ____________________________________________ Date:

Position Title: ____________________________________________ 6-24-15fw