Family Functional Assessment
Information in this form must be transferred into KIDS.
Child Welfare (CW) worker initiates the Family Functional Assessment during the first
30 days of voluntary services, no later than 60 days after child(ren)'s removal, or prior to
the Dispositional Hearing, whichever comes first, and continually reviews throughout the
duration of the case, including, at a minimum, when:


there is a substantial change in the family structure, such as one parent leaves or
a new person enters the family; and
plans are to return a child(ren) home.
Case name
Assessment meeting date(s)
Who is involved in the assessment process? The family's active involvement in
describing their own needs and determining the services that will best meet those needs
is a critical part of the process.
Name
Relationship to child(ren)/family
Form 04KI028E revised 3-11-2010 may continue on next page, page 1 of 23
Family telling their
story-reason for
involvement
Questions to actively
engage the
caregiver(s)
Assessing the parent(s)' understanding of the
seriousness of the concerns regarding their
child(ren)'s safety.


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
What happened that made someone worried enough about
your child(ren) to contact Child Welfare?
Do you believe there should be concerns about the safety
of your child(ren)?
Are you afraid of what your child(ren) might think?
How do you think the rest of your family is going to respond
to our involvement?
What scares you the most about Child Welfare involvement?
Information compiled from family and other individuals who know the family:
Examples of
protective capacities
on which you
can build
The parent(s) acknowledges that there is a problem and
is willing and open to intervention.
Parent(s) recognizes their limitations and is willing to work to
improve parenting skills or consider alternative caregivers.
Parent(s), while uncomfortable, does what it takes to meet
child(ren)'s needs - regardless of own feelings of pride.
Other. Describe:
Examples of
behaviors/conditions
to consider
Significant denial as to the reasons the family is involved
in the system.
Lack of parental acknowledgement and understanding of
the issues.
A seeming lack of motivation by one or more caregivers
to change their approach to parenting.
Other, describe:
Form 04KI028E revised 3-11-2010 may continue on next page, page 2 of 23
Kinship care, family
and tribal connections,
and community
support system
Assessing the parent(s)' paternal and maternal
kinship, tribal, community, supports, and
other connections.
Questions to actively
engage the caregiver(s)


Some of these
questions may be
asked to parent(s)
and child(ren)






Who do you consider family/kin?
Who would you want to take care of your child(ren) if
you could not?
Are you close to people within any church or community
group?
Are you a member of a tribe? If so, tell me about
your involvement?
Sometimes when you have a question or need help as
a parent it is hard to ask for help. Who do you go to
during these times?
Other than you, who is important to your child(ren)?
Are both parents actively involved in caring for the
child(ren)? If not, is there a way to contact and connect
with the absent parent?
Does your family have any customs or traditions that
are important for me to know?
Information compiled from family and other individuals who know the family:
Examples of protective
capacities that can
keep children safe
Family is able to name connections and support
systems that are there to provide help.
Parent(s) has connections and support systems from
which they can seek help when they are needed.
Parent(s) is involved with positive activities outside
the home that relieves family stress.
Family is actively involved with their tribe.
Form 04KI028E revised 3-11-2010 may continue on next page, page 3 of 23
Kinship care, family
and tribal connections,
and community
support system
Assessing the parent(s)' paternal and maternal
kinship, tribal, community, supports, and
other connections.
Examples of
behaviors/conditions
to consider
Parent(s) does not seem to trust anyone to get close.
Family connections have been severed.
Family lives in a geographically isolated area.
Caregiver is not sure if kin are able or willing to meet
the needs of the child.
The family experienced a recent loss of a family
member/kin/community that served as a support
system.
NOTE:
 Strength – Family is able to identify multiple people they consider to be
supports in their lives; have connections to multiple groups, organizations, or
community supports; regularly looks to others with questions and for help.
 Adequate - Family is able to identify a few people they consider to be supports
in their lives; has connections to a few groups, organizations, or community
supports; sometimes looks to others with questions and for help.
 Area of concern - Family is able to identify only one person they consider to be
a support; has little opportunity for interaction with groups or community
supports; infrequently looks to others for help.
 Problem - Family is not able to identify anyone they consider to be supports in
their lives; have no connections to groups, organizations, or community
supports; rarely or never looks to others with questions or for help.
Based on critical thinking, your discussion about kinship/neighborhood support, and
the safety threats identified in the Assessment of Child Safety, rate the family's
functioning in this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for intervention in this area to keep
the child(ren) safe?
Yes
No If yes, describe the:
behaviors or conditions that need to be changed (specific safety threat):
desired result (description of change required):
to do (intervention/services):
Form 04KI028E revised 3-11-2010 may continue on next page, page 4 of 23
Housing/food/basic
needs
Assessing the parent(s)' perspective of how their child(ren)'s
basic needs, including housing and food, are met.
Questions to
actively engage
the caregiver(s)


Some of these
questions may
be asked to
parent(s) and
child(ren)



Where is the best place you ever lived? Why did you like it?
Most months, are you able to pay rent and utilities? If not
what do you do?
Do you ever worry if your house or your neighborhood is
unsafe?
Do you ever go to bed hungry because there is no food in
the house?
Do you have transportation to meet your family's needs?
Information compiled from family and other individuals who know the family:
Examples of
protective
capacities on
which you
can build
Family is able to meet their basic needs either on their
own or from their community.
Family has a plan regarding where to go if things become
financially difficult for them.
Family is able to maintain income sufficient to meet
basic needs.
Examples of
behaviors/
conditions
to consider
Family is homeless and lacks ability to meet basic needs,
such as food or shelter.
Family moves frequently.
House is not clean/in need of repair and there are health
risks to child(ren) and adults.
Parent(s) report no concern about the cleanliness or the
condition of the home.
Utilities/water are disconnected currently or on a frequent
basis.
Yard is filled with debris and hazards.
Form 04KI028E revised 3-11-2010 may continue on next page, page 5 of 23
Housing/food/basic
needs
Assessing the parent(s)' perspective of how their child(ren)'s
basic needs, including housing and food, are met.
NOTE:
 Strength - Family has consistent, stable housing and has no trouble meeting
financial obligations; home is clean and in good condition. Family clearly states
they manage money wisely and are able to provide for all of the family's needs,
with money left over.
 Adequate - Family has some problems in maintaining the same residence, or
some debts, but this does not prevent the family from meeting basic needs for food,
rent, etc. Home has some clutter, but most safety precautions are taken.
 Area of concern - Family moves frequently and has problems meeting financial
obligations and basic needs; home is in need of some repair which could result in
safety concerns if left unattended; family occasionally relies on shelters, food
banks, and other community resources to help with basic needs.
 Problem - Family is homeless, threatened with eviction, or does not have stable
housing; unable to meet basic needs of the child(ren). Home in serious disrepair,
which poses a threat to the child(ren)'s safety; often relies on shelters, food banks,
and other community resources to help provide for family's basic needs.
Based on critical thinking, your discussion about housing/food/basic needs, and the
safety threats identified in the Assessment of Child Safety, rate the family's current
functioning in this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for intervention in this area to keep
the child(ren) safe?
Yes
No If yes, describe the:
behaviors or conditions that need to be changed (specific safety threat):
desired result (description of change required):
to do (intervention/services):
Form 04KI028E revised 3-11-2010 may continue on next page, page 6 of 23
Medical needs
of the family
Questions to
actively engage
the caregiver(s)
Some of these
questions may be
asked to parent(s)
and child(ren)
Assessing the parent(s)' perspective
of family's medical needs

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Do you have a doctor (medical provider)? When was the
last time you saw the doctor?
Does your child(ren) have a doctor (medical provider)? Is
your child(ren)'s immunizations current?
Do you have a dentist? Does your child(ren) have a dentist?
Do you have any health conditions that make caring for
your child(ren) difficult?
Are there any medications that you are taking (or doctor
recommends that you take)?
Is there anything that prevents you from getting the
medical or dental care that you or your child(ren) need?
Information compiled from family and other individuals who know the family:
Examples of
protective capacities
on which you
can build
Family has a doctor or medical provider.
Family has a dentist.
Parent(s) maintains their own health by having check ups.
Medical conditions are managed through medical care.
Examples of
behaviors/conditions
to consider
Parent(s) has a medical condition that does not allow
them to care for their child(ren) - no outside support.
A child(ren) within the family has special physical or
developmental needs that are particularly demanding.
Cannot meet ongoing medical needs of the family due to
lack of resources.
Child(ren) has medical condition that places significant
stress on the family physically, emotionally, and/or
financially, and family is not managing the stress well.
Parent(s) does not maintain child(ren)'s immunizations
or provide for child(ren)'s medical care.
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Medical needs
of the family
Assessing the parent(s)' perspective
of family's medical needs
NOTE:
 Strength - Is healthy and able to care for child(ren); expresses medical and
dental care as a high priority in the family by going to regular check ups; is able
to describe child(ren)'s medical/dental needs and actively participates in
addressing those needs.
 Adequate - Has some health issues that moderately impact their ability to care
for their child; is unable to fully describe their child(ren)'s medical/dental needs;
does not actively participate in addressing child(ren)'s medical/dental needs.
 Area of concern - Parent(s) has numerous health issues that significantly
impact their ability to care for their child(ren); does not consistently understand
or demonstrate the need to provide for their child(ren)'s medical/dental care;
parent(s) often relies on others to take the active role in addressing their
child(ren)'s medical/dental needs.
 Problem - Parent(s) has severe health issues that seriously impact their ability to
care for the child(ren); does not place any importance on medical/dental care in
the family as demonstrated by rarely obtaining healthcare; is unable to describe
child(ren)'s medical/dental needs and not involved in helping to address them.
Based on critical thinking, your discussion about medical/dental care, and the safety
threats identified in the Assessment of Child Safety, rate the family's current functioning
in this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for intervention in this area to keep
the child(ren) safe?
Yes
No If yes, describe the:
behaviors or conditions that need to be changed (specific safety threat):
desired result (description of change required):
to do (intervention/services):
Form 04KI028E revised 3-11-2010 may continue on next page, page 8 of 23
Family's behavioral
and emotional health
Questions to
actively engage
the caregiver(s)
Assessing the parent(s)' perspective on the family's
behavioral health issues and needs.

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

Questions to
actively engage
the child(ren)


What is the best part of your day? What is the worst?
Have you lost interest or pleasure in things you usually
cared about or enjoyed?
As a child did you ever experience any type of abuse
or neglect?
Do you or your child(ren) have a behavioral health diagnosis?
If so, are you or your child(ren) on any medication? Do you
or your child take the medication as prescribed?
Do you have any concerns about your child(ren)'s
behavioral health?
Do you ever worry about your parent(s)? If yes, when?
What is the best time with your Mom or Dad? What is the
worst time?
Information compiled from family and other individuals who know the family:
Examples of
protective capacities
on which you
can build
Parent(s) has sought or is seeking mental health treatment
for self or child(ren).
Parent(s) consistently follows recommendations from
therapist for self or child(ren).
Parent(s) is aware of his or her own limitations due to their
behavioral health issues and knows how to obtain help
as needed.
Examples of
behaviors/conditions
to consider
Parent(s) appears depressed, unkempt, sleeping all-day,
tearful - unable to plan for the needs of the child(ren).
Parent(s) is inconsistent in following recommendations
from therapist for self or child(ren).
Parent(s) or child(ren) is inconsistent in taking medication
as prescribed.
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Family's behavioral
and emotional health
Assessing the parent(s)' perspective on the family's
behavioral health issues and needs.
Parent(s) appears unable to track on any single topic,
cannot follow instructions or retain information easily.
Parent(s) has special physical or developmental needs
that limit their ability to parent.
NOTE:
 Strength - Gives no indication of behavioral health issues; appears able to deal
with positive and negative experiences; has an identified behavioral health issue,
but is currently receiving appropriate treatment and taking medication as
appropriate; consistently displays appropriate behavior in a variety of situations;
demonstrates ability to deal with crises; has self awareness of behavioral health
issues/treatment.
 Adequate - Gives an indication of limited behavioral health issues; appears able to
deal with some situations, but needs and receives assistance to deal with others; is
receiving and participating in limited treatment for behavioral health issues; displays
some inconsistent behavior depending on the situation; is able to deal with some
crises; has limited self awareness related to behavioral health issues.
 Area of concern - Gives indication of several behavioral health issues; appears to
have difficulty assessing needs and dealing with crises; often displays inconsistent
behavior; has little self awareness and does not receive or participate in treatment
for behavioral health issues.
 Problem - Parent(s) indicates serious behavioral health issues; appears unable to
deal with most situations without additional support and support is not regularly
sought out; does not receive or participate in treatment for behavioral health issues;
parent(s) displays extremely inconsistent behavior; lacks the ability to deal with
crises as they arise; no self-awareness of their behavioral health issues or needs.
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Family's behavioral
and emotional health
Assessing the parent(s)' perspective on the family's
behavioral health issues and needs.
Based on critical thinking, your discussion about family's behavioral health, and the safety
threats identified in the Assessment of Child Safety, rate the family's current functioning in
this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for intervention in this area to keep
the child(ren) safe?
Yes
No If yes, describe the:
behaviors or conditions that need to be changed (specific safety threat):
desired result (description of change required):
to do (intervention/services):
Parent(s)'
substance use
Questions to
actively engage
the caregiver(s)
Assessing the parent(s)' involvement
with alcohol and drugs





How do you get through a bad day?
What is one way that you handle stress?
Do you ever use prescription medication in ways other
than prescribed?
Do you have concerns about the use of alcohol, drugs, or
other substances by others in the home?
Has your drinking or drug use caused job, family, or
legal problems?
If substance use/abuse was not identified on Form 04KI030E,
Assessment of Child Safety, in Section III; Six key questions
in gathering information. Use the UNCOPE screening tool.
Ask as written:
U
N
C
In the past year, did you drink or use drugs more than you
meant to?
Mother:
Yes
No Father:
Yes
No
Have you ever neglected some of your usual responsibilities
because of using alcohol or drugs?
Mother:
Yes
No Father:
Yes
No
Have you felt you wanted or needed to cut down on your
drinking or drug use in the last year?
Mother:
Yes
No Father:
Yes
No
Form 04KI028E revised 3-11-2010 may continue on next page, page 11 of 23
Parent(s)'
substance use
Assessing the parent(s)' involvement
with alcohol and drugs
O
P
E
Has anyone objected to your drinking or drug use?
Mother:
Yes
No Father:
Yes
No
Have you found yourself thinking a lot about drinking or
using drugs?
Mother:
Yes
No Father:
Yes
No
Have you ever used alcohol or drugs to relieve emotional
discomfort, such as sadness, anger, or boredom?
Mother:
Yes
No Father:
Yes
No
NOTE: If the parent(s) answers yes to two or more of the
screening questions and based on critical thinking, a concern
is identified that substance use/abuse may be impacting the
care of the child(ren). Refer the parent(s) for a formal
substance abuse assessment.
Information compiled from family and other individuals who know the family:
Examples of
protective capacities
on which you
can build
Parent(s) can describe their relapse plan.
Parent(s) completed treatment and reports no further
abuse of drugs or alcohol.
Parent(s) attends NA, AA, or other support group as
recommended by a treatment provider or sponsor.
Examples of
behaviors/conditions
to consider
There is a history of substance abuse by the parent(s).
Parent(s) engages in substance abuse that results in a
disruption in the family and reduces the parent(s)' ability
to care for the child.
Parent(s) reports no desire to change substance abuse
patterns.
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Parent(s)'
substance use
Assessing the parent(s)' involvement
with alcohol and drugs
Parent(s) appears to be self-medicating through use of
prescription drugs, drugs, and/or alcohol.
Parent(s) is using multiple drugs/substances.
Parent(s) is experiencing health problems as a result of
substance abuse.
NOTE:
 Strength - Gives no indication of abusing alcohol or drugs; demonstrates ability to
deal with life stressors (positive and negative) without the need for alcohol/drugs;
displays self-awareness and identifies as past abuser who participated in treatment
and has remained in recovery for some time; show no lack of discomfort in talking
about substance abuse issues.
 Adequate - Indicates use of alcohol and/or drugs, but only occasionally in excess;
relates some instances of reduction in parenting skills due to alcohol/drugs; identifies
as a past abuser of drugs/alcohol, but only recently began treatment.
 Area of concern - Others in household are abusing and not receiving treatment;
others express concern of primary caregiver's excessive use of drugs/alcohol; no
recognition of the impact of their drug use on other family members.
 Problem - Parent(s) indicates they use alcohol and/or drugs on a regular and
consistent basis; displays an inability to parent as a result of alcohol and/or drug use;
has no interest in participating in treatment; parent(s) displays discomfort in talking
about substance abuse issues (denial) and expresses an inability to deal with life's
stressors; denies their need for treatment.
Based on critical thinking and your discussion about parent(s)' substance abuse and
safety threats identified in the Assessment of Child Safety, rate the family's current
functioning in this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for intervention in this area to keep
the child(ren) safe?
Yes
No. If yes, describe the:
behaviors or conditions that need to be changed (specific safety threat):
desired result (description of change required):
to do (intervention/services):
Form 04KI028E revised 3-11-2010 may continue on next page, page 13 of 23
Violence in
the home
Ensure that this area is addressed
with partners individually.
Questions to
actively engage
the caregiver(s)

Questions to
actively engage
the child(ren)







Describe an example of a good and a bad time with your
spouse/significant other.
All couples argue; how do you resolve conflict in your family?
Have you ever been afraid of your partner?
Have you or your partner ever been injured in an
argument? Have the police ever been called to the home?
Do you have a pet - if so have you ever been worried
about the safety of your pet during or after an argument?
When you feel afraid what do you do?
What happens in your family when there is an argument?
Have you ever seen or heard someone in your family hurt
another family member?
Information compiled from family and other individuals who know the family:
Examples of
protective capacities
on which you
can build
Parent(s) are able to identify methods for non-violent
resolution of conflicts and can provide examples of times
they have successfully used these methods.
Non-offending parent protects child(ren) by sending
child(ren) to relatives, friends, or other safe place.
Person who commits the violence is in treatment for
domestic violence issues.
Examples of
behaviors/conditions
to consider
Household has a history of family violence.
One parent(s) is afraid of another adult within the family.
Child(ren) attempts to intervene during a family violence
incident.
Child(ren) is injured during a family violence incident.
Pet is injured during or following a family argument.
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Violence in
the home
Ensure that this area is addressed
with partners individually.
NOTE:
 Strength - Indicates violence has never occurred in the home; discusses a
variety of non-violent conflict resolution strategies that are used; demonstrates
comfort in talking about family safety and non-violent conflict resolution; and how
the family resolves disagreements.
 Adequate - Indicates that violence occurred in the home in the past, not recently;
discusses a few non-violent conflict resolution strategies that are used in the
home; expresses no fear about their child(ren)'s safety, but may have fear of
personal safety based on past experiences; has discomfort when talking about
conflict resolution strategies.
 Area of concern - No safety plan in place in event of serious conflict or threatened
harm; injury from recent incident of domestic violence (past six months).
 Problem - Parent(s) indicates that violence has occurred in the home recently; is
unable to describe any non-violent conflict resolution strategies used in the home;
demonstrates discomfort in talking about how family resolves disagreements;
demonstrates or expresses ongoing fear about their own safety and their
child(ren)'s safety.
Based on critical thinking and your discussion about violence and safety threats in the
home identified in the Assessment of Child Safety, rate the family's current functioning
in this area.
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for intervention in this area to keep
the child(ren) safe?
Yes
No If yes, describe the:
behaviors or conditions that need to be changed (specific safety threat):
desired result (description of change required):
to do (intervention/services):
Form 04KI028E revised 3-11-2010 may continue on next page, page 15 of 23
Day-to-day parenting
Questions to
actively engage
the caregiver(s)
Assessing day-to-day parenting skills.






Questions to actively
engage the child(ren)



What do you think your child(ren) needs from you as a
parent with regard to supervision, play, and school?
In what ways do you think that you are meeting your
child(ren)'s needs?
Are you where you would like to be as a parent? If not,
what will it take to get you there?
What is the most positive thing that you can tell me about
your child(ren)? For example: What can he or she do that
makes you most proud?
How do you know what's normal development for your
child? For example: How did you know or will you know
when it was time to toilet train your child(ren), for your
child(ren) to play outside alone, etc?
Describe what you do when both you and your child(ren)
have a need, but you are unable to meet both.
What is the best time at home? What is the worst time
at home?
What would you like to see change about your family?
Do you like to spend time with your family?
Information compiled from family and other individuals who know the family:
Examples of
protective capacities
on which you
can build
Parent(s) demonstrate ability to put the child(ren)'s
needs above his or her own.
Parent(s) is interested in becoming a better parent and
is willing to try new parenting ideas.
Parent(s) understands what the child(ren) needs at
different developmental stages.
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Day-to-day parenting
Examples of
behaviors/conditions
that require further
consideration
Assessing day-to-day parenting skills.
Child(ren) appears fearful of parent(s).
Parent(s) has little or no concept of child(ren)'s needs.
Parent(s) is focused on self more than child(ren) - is
unable to put the child(ren)'s needs above his or her own.
Parent(s) is unable to describe the child(ren) in a
positive manner.
Parent(s)' response and tone of voice is generally angry
or harsh with the child(ren).
NOTE:
 Strength - Parent(s) is aware of and is able to meet the majority of the child(ren)'s
needs; parent(s) loves the child(ren) and wants what is best for the child(ren);
parent(s) has the capacity and interest to parent the child(ren); parent(s) uses
positive statements about parenting; parent(s) has an obvious knowledge about the
child(ren)'s current capacity and functioning.
 Adequate - Parent(s) is not openly affectionate, however child(ren)'s needs are
met; most expectations are age-appropriate. Parent(s) has a limited capacity to
care for the child(ren) and limited knowledge of child(ren)'s current capacity
and functioning.
 Area of concern - Parent(s) has a limited capacity to care for their child(ren);
limited knowledge of child(ren)'s needs, resulting in child(ren)'s regression in
behavior and emotional state.
 Problem - Parent(s) is unable to form a close relationship with child(ren); parent(s)
responds negatively or harshly to child(ren) or puts their own needs above their
child(ren)'s needs; parent(s) has little or no knowledge of child(ren)'s current
capacity and functioning.
Based on critical thinking and your discussion about day-to-day parenting, and safety
threats identified in the Assessment of Child Safety, rate the family's current
functioning in this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for intervention in this area to keep
the child(ren) safe?
Yes
No If yes, describe the:
behaviors or conditions that need to be changed (Specific safety threat):
desired result (description of change required):
to do (intervention/services):
Form 04KI028E revised 3-11-2010 may continue on next page, page 17 of 23
Child specific assessment:
This section should be completed individually for each child involved in the case. The
paper version of this form will require that this section be copied based upon the
number of active children in the case.
Child's emotional and
developmental needs
Questions to actively
engage child
Assessing the child's perspective of their emotional
and developmental needs.





Is there anything that is bothering you? If yes, what?
When you feel happy what do you do? Sad?
Do you have a best friend?
If you have a problem, who do you talk to about it?
What do you like best about yourself? Least?
Information compiled from family and other individuals who know the family:
Examples of successful
child behaviors which
you can build
Child has specific adult(s) he or she trusts to talk to.
Child is able to verbalize how they feel and what
they need.
Examples of
behaviors/conditions
to consider
Child is sexually active and does not practice safe
sex.
Child is isolated and has no one to talk to.
Child is untrusting and refuses to talk or is unable to
verbalize feelings.
Child is significantly developmentally delayed with
no supports.
Child cannot identify anything that they like about
themselves.
Form 04KI028E revised 3-11-2010 may continue on next page, page 18 of 23
Child's emotional and
developmental needs
Assessing the child's perspective of their emotional
and developmental needs.
NOTE:
 Strength - Gives no indication of behavioral health issues or developmental needs;
appears able to deal with positive and negative experiences; has an identified
behavioral health issue, but is currently receiving appropriate treatment and taking
medication as appropriate; consistent display of appropriate behavior in a variety of
situations; demonstrated ability to deal with crises; self awareness of behavioral
health issues/treatment.
 Adequate - Gives an indication of limited behavioral health issues; appears able to
deal with some situations, but needs and receives assistance to deal with others; is
receiving and participating in limited treatment for behavioral health issues and/or
developmental needs; displays some inconsistent behavior depending on the
situation; is able to deal with some crises; has limited self awareness related to
behavioral health issues.
 Area of concern - Gives indication of several behavioral health issues; appears to
have difficulty assessing needs and dealing with crises; often displays inconsistent
behavior; has little self awareness and does not receive or participate in treatment
for behavioral health issues.
 Problem - Child indicates serious behavioral health issues; appears unable to deal
with most situations without additional support and support is not regularly sought
out; does not receive or participate in treatment for behavioral health issues;
parent(s) displays extremely inconsistent behavior; lacks the ability to deal with crises
as they arise; has no self-awareness of their behavioral health issues or needs.
Based on critical thinking and your discussion about emotional and developmental
needs, rate the child's functioning in this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for services in this area?
Yes
No If yes, identify the services:
Form 04KI028E revised 3-11-2010 may continue on next page, page 19 of 23
Child's vocational-educational
information/independent
living services
Assessing the child's perspective
of their education.
Questions to actively engage 
the child





Questions to actively engage 
the caregiver(s)





What grade are you in?
What do you think about school? Do you have a
favorite subject or class?
Favorite teacher?
Do you ever have problems hearing what your
teacher is saying? Do you have any trouble
seeing or reading the board?
What is the hardest part of school for you? What
is the best part?
Do you ever skip school? Where do you go
when you skip school?
Do you assist your child in completing their
homework or read with your child?
Do you talk to your child's teachers? Go to
parent teacher conferences?
What is your greatest concern about your child's
education? Do they have an Individual education
plan (IEP)?
Does your child struggle with ADD/ADHD?
Do you feel that the child's educational needs
are being met? What about sports, music, or
other school activities?
Has your child ever skipped school? What did
you do?
Information compiled from family and other individuals who know the family:
Examples of successful child
behaviors on which you
can build
Child attends school regularly and appears to
enjoy going to school
Child makes good grades.
Child has good behavior while at school.
Child's special needs are being met.
Form 04KI028E revised 3-11-2010 may continue on next page, page 20 of 23
Child's vocational-educational
information/independent
living services
Assessing the child's perspective
of their education.
Examples of protective
capacities of caregiver(s) on
which you can build
Parent(s) is actively supportive and involved in
their child's education.
Parent(s) is aware of child's educational needs
and actively advocates for them.
Parent(s) reads to child or assists in homework.
Examples of
behaviors/conditions
to consider
Child is frequently truant - parent(s) is aware
but does not appear to take any action.
Child does not concentrate at school - per
teacher report.
Child struggles with ADD or ADHD.
Child does not like school.
Parent(s) is uninvolved and does not seem
to know about child's educational issues
and needs.
Parent(s) reports the child is not getting his or
her special needs met.
NOTE:
 Strength - Child has a consistent, excellent attendance record at school and a
very good academic record. Child states he or she enjoys school and describes
school as a priority.
 Adequate - Child has a good attendance record at school and an average
academic record; expresses some dislike for school; recognizes that school and
education are important, but not a high priority.
 Area of concern - Occasionally truant; pattern of declining grades; recognizable
loss of interest in school.
 Problem - Child has poor school attendance, a poor academic record, and does
not enjoy school; child does not believe school and education are important.
Based on critical thinking and your discussion about child's educational information,
rate the child's functioning in this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for services in this area?
Yes
No If yes, identify the services:
Form 04KI028E revised 3-11-2010 may continue on next page, page 21 of 23
Child's
substance use
Additional questions
to actively engage to
engage the child
Assessing the child's involvement
with alcohol and drugs.





Questions to
actively engage
the caregiver(s)



How do you get through a bad day?
Do your peers ever pressure you to drink or use drugs?
What do you say?
Have you ever drank or used drugs and had something
bad happen? If so, what happened?
Do others in the home use alcohol or other drugs?
How easy is it to get alcohol or drugs?
Do you ever worry about your child's drinking or use of
drugs?
Does your child seem to spend a lot of money - and you
cannot account for it?
Does your child have friends that use drugs?
Information compiled from family and other individuals who know the family:
Examples of
successful child
behaviors on which
you can build
Child can describe his or her relapse plan.
Child completed treatment and reports no further abuse
of alcohol or drugs.
Child attends AA, NA, or other support group as
recommended by a treatment provider.
Child says he is able to say no to peers.
Child admits using and has frank conversations
with parent(s).
Child is able to express concerns about personal use.
Examples of
behaviors/conditions
to consider
Child reports a history of drinking or drug use.
Child engages in substance use that results in
disruption in school, work, and family life.
Child reports a loss of memory resulting from drug
alcohol use.
Child has had accidents as a result of binge drinking
drug use.
Child is experiencing health problems as a result
drinking or drug use.
Form 04KI028E revised 3-11-2010 may continue on next page, page 22 of 23
a
or
or
of
Child's
substance use
Assessing the child's involvement
with alcohol and drugs.
NOTE:
 Strength - Gives no indication of abusing alcohol or drugs; demonstrates ability
to deal with positive and negative life stressors without the need for substances;
identifies as a past abuser who participated in treatment and remains in recovery;
lacks discomfort in talking about substance abuse issues; self-aware of past
substance abuse issues and challenges of remaining in recovery.
 Adequate - Uses alcohol/drugs occasionally; relates limited instances where
friends/school has been negatively impacted; identifies as a past abuser who is in
treatment, but not completed; displays limited awareness of past substance
abuse issues; displays mixed ability to deal with life stressors.
 Area of concern - Uses alcohol/drugs occasionally in excess; relates instances
where friends/school have been negatively impacted; is uncomfortable talking
about substance abuse issues; identifies as a past abuser who is not
in treatment.
 Problem - Child indicates he or she uses drugs consistently; indicates school and
friendships have been negatively impacted; has no interest in participating in
treatment; refuses to talk about substance abuse issues, possible denial;
expresses inability to deal with life stressors; overstates ability to handle
substance abuse issues without help.
Based on critical thinking and your discussion about child's substance abuse, rate the
child's current functioning in this area:
Strength
Adequate
Area of concern
Problem
If rated area of concern or problem, is there a need for services in this area?
Yes
No If yes, identify the services:
Form 04KI028E revised 3-11-2010 may continue on next page, page 23 of 23