CP&P Form 26-53c
(rev. 12/2006)
State of New Jersey
DEPARTMENT OF CHILDREN AND FAMILIES
Division of Child Protection and Permanency
INDIVIDUAL AND FAMILY ASSESSMENT OUTLINE-ADOPTION
Child Summary Outline-Part B
I.
Child to be Adopted
Name:
Date of Birth:
Place of Birth:
Race:
Sex:
Ethnicity:
Religion:
Social Security Number:
Attach child’s picture
Attach picture of child
NARRATIVE: Worker should know child well enough to personalize this section by focusing on what
makes this child special, likable and unique. For children age three and under, it is permissible to combine
the elements of Section I and Section II into one overall child narrative.
Provide a current description of the child in the following areas:
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Personal Attributes:
physical description, personality traits, individual abilities, special
needs, likes/dislikes, etc.
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Educational Information:
name of school child attends, grade level, behavior as reported by school,
current classification (if any), academic performance, special services
child receives, educational goals, extra curricular activities, etc.
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Social Relationships:
behavior with adults and peers, response to adult guidance, response to
discipline, interaction with other children, participation in child-specific
activities (scouts, sport teams, church groups), social aptitudes.
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Family Relations:
attachment to birth parents, attachment to siblings, need for continuing
contact with specific family members, connections to foster siblings, etc.
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Health:
diagnosed or reported mental or physical conditions, need for specialized
care, routine medical care, etc. If the child is medically fragile, include a
full description of the reason for this classification. If the child has since
been de-classified, detail the child’s actual improvements and include the
date the child was de-classified.
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Knowledge & Understanding
of Adoption:
knowledge of own birth family history, understanding of placement
situation, understanding and acceptance of adoption; include information
about the child’s preparation for adoption and reaction to it.
CP&P Form 26-53c
(rev. 12/2006)
II.
Birth and Developmental History
Narrative description of the child from birth using factual information from hospital records,
medical records, school reports, psychological or psychiatric evaluations and therapy reports. The
summary must include the date and result of all medical, psychiatric or psychological testing
completed on the child even if the outcome did not reveal long-lasting problems.
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III.
History of prenatal care, time and place of birth, type of delivery, APGAR scores, weight and length at
birth, medical concerns/treatment, date and result of HIV testing (if applicable), date and result of drug
screening (if applicable) and whether child experienced drug withdrawal at birth, physical description as
noted in birth records.
Age at which child reached developmental milestones such as sitting up, crawling, walking, talking, toilet
training, self care, etc. Note any specific difficulties or services child required.
Abuse or neglect experiences
Placement history
Educational experiences; Child Study Team evaluations
Medical and health history that includes diagnosed or reported emotional, mental or physical conditions,
tests and results related to these conditions, specialized care, routine medical care, special needs.
Reason for Adoption Plan
Describe the circumstances which lead to the selection of adoption as the case goal in a clear,
concise summary that is informational in tone rather than legalistic. The goal of this section is to
develop a narrative social summary that highlights family history, including both positive and
negative aspects.
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IV.
General overview of CP&P involvement with family.
When and why this particular child entered resource family care and the persistent family problems that
lead to a failure to reunify child with family.
Indicate how and when the child became available for adoption and whether current adoption plan is
resource parent adoption or placement in a selected adoptive home.
Family Information
A.
Birth Mother: narrative description of the birth mother includes:
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Individual Traits –
date and place of birth, race, religion, nationality/ethnicity, physical
description, personality, skills and interests
Social History
–
family background, marital/civil union history, social relationships
Education and Employment History
Parenting Role –
age when first child was born, available family support (or not),
caregiving abilities and deficits, history of relationship with child, etc.
Feelings about adoption and/or hopes for child
CP&P Form 26-53c
(rev. 12/2006)
B.
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C.
Siblings: narrative description of each sibling that includes:
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V.
Birth Father: narrative description of the birth father that includes:
Individual Traits –
date and place of birth, race, religion, nationality/ethnicity, physical
description, personality, skills and interests
Social History –
family background, marital/civil union history, social relationships
Education and Employment History
Parenting Role –
age when first child was born, available family support (or not), caregiving
abilities and deficits, history of relationship with child, etc.
Feelings about adoption and/or hopes for child
Biological Relationship (brother, sister, half-brother, half-sister)
Individual Traits –
date and place of birth, race, religion, ethnicity, physical description,
personality, skills and interests
Education and Health History
Relationship with Child to be Adopted – have these children lived together, is there a history of
sibling visitation, how do children interact with each other, etc.
Present Living Situation and Permanency Goal
Adoption Placement Issues
Include in this section information specific to this child’s adoption:
 legal status
 involvement with ongoing sibling visitation
 child’s understanding and acceptance of adoption plan
 preparation of child for adoption
 Life Book status
 specific need for any post-placement services
Prepared By (Print Name):
VI.
Date:
Signatures and Dates
Permanency Worker:
(Name)
(Signature)
Date
Adoption Specialist:
(Name)
(Signature)
Date
Supervisor of Permanency Worker: (Name)
(Signature)
Date
Adoptive Parent
Date
Adoptive Parent
Date