Kenna Pruitt, Family Partnerships Manager
September 1, 2011
Performance Standards,
ACYF-PI-HS-95-0 (Program Instruction)


Record Keeping
C. Family records.
Grantee and delegate agencies must establish and maintain
records on individual families, which contain:
(1) Recruitment, enrollment, and attendance data, including
enrollment forms and income documentation;
(2) Family Partnership Agreements and ongoing documentation
of progress toward meeting family goals, including information
about the services provided to or arranged for families, service
referrals, and follow-up reports;
(3) Reports on home visits and staff-parent conferences; and
(4) Documentation of all contacts with the child's family related
to poor or irregular attendance, in accordance with the
requirements of 45 CPR 1305.8 on attendance.
Strength Assessment
Family Home Visit Form
Family Partnership Agreement
Family Partnership Agreement—
Goal Sheets
FPA- Goal Sheets
FPA- Goal Sheets
Child Plus FPA
1
2
3
4
1. In family goal setting process- Only select Yes if family is doing FPA
2. Family Partnership Agreement- Only select Yes if family is doing FPA
3. Effective Date-First date is the date you complete FPA, the to date is last day
of school
Child Plus FPA
Family Partnership Agreement
Remember to complete referrals for FPA
objectives
 You can have one event as FPA, and
then multiple actions under that event

Referral Form
(top half of form goes in brown folder)
Referral Form—
(bottom half of form goes to parent to give to agency)
1.
2
3
1. Add Event
2. Enter Date
3. Event Type-Need Identified
4
5
6
4. Description-Type concern
5. Service Area-choose from drop down menu
6. Issue-choose from drop down menu
8
7
9
7. Source of Info-choose who you obtained information
from
8. Family Member-this is who you spoke with about
referral
9. Event Notes-Here you describe exactly what is needed
10
10. Add Action- Here you will add any action that goes
with the event above. For example, referrals to needs
that have been identified.
12
13
14
12. Scheduled-Date you plan to provide referral
13. Action Date-date you provided the referral
14. Referred To-Drop down menu connects to resources in
Child Plus
15. Referral Type-Choose verbal or written
15
16
17
18
19
16. Type of Contact-this is the physical location where you gave
the family referral
17. Description-type here what family needs
18. Status-choose here the status of referral ONLY put Action
Completed if family received services
19. Action Notes-explain here what and where you referred
family to
Referral Follow-Up Form
Referral Follow-Up Form
1
2
3
4
5
6
7
8
1. Add Action- you will add an action to the same event as the need identified
2. Action Type-follow up
3. Scheduled-date you plan to follow up
4. Action Date-date you actually followed up
1
2
3
4
5
6
7
8
5. Type of Contact-Choose how you contacted family for follow-up
6. Description-what you were following up on
7. Status-choose the status of referral Only choose Action Completed if
family received services
8. Action Notes-explain here what you found out about the referral
Crisis Intervention Form
Crisis Intervention Form
Only Difference is Event Type
1
1. Event Type-Select Emergency Crisis (everything else
is the same as referral
2. 2. Continue to use Part 2 actions for referral and
follow-up
Crisis Intervention Form

Once you have completed crisis
intervention form, referral form and all
contact notes, Email FCP Manager,
child’s name and date of crisis.
Crisis Intervention Follow-Up
Crisis Intervention Follow-Up
In Child Plus

Your follow-up for crisis is done the
same way as referral. In the second
part, as an action.
Questions/Comments