Exhibit H Clinical Family Assessment rev 10-23-15.doc
DOC document 42 KB Posted
- Attached to
- Master Agreement AZ|CTR064201
- Contract number
- CTR064201
- Issued by
- Arizona
About this file
This document is an assessment template for the State of Arizona Department of Child Safety, located in Phoenix, AZ. The form is titled "Clinical Family Assessment" and is designed to comprehensively document family and child welfare details for case management purposes. The exhibit appears to be a standardized form used by the state's child welfare agency to collect critical information about families under investigation or receiving services.
The assessment template requires detailed information across multiple dimensions, including family composition, physical description, background, education, health history, support systems, criminal history, domestic violence, substance use, psychological treatment, and parenting capabilities. The document specifically calls for information about both family members and children, with sections dedicated to assessing child development, family dynamics, school performance, and recommendations for potential interventions or services. While no specific contract pricing or renewal terms are evident, the form is clearly an administrative tool for systematic family and child welfare documentation within the Arizona Department of Child Safety's case management process.
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Text version
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
File details come from the government source that posted it. Updated .