Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
Case Name:
Case ID Number:
Family Name:
Address:
City, State Zip:
County:
(Leave in all above prompts)
-Throughout study, refer to adults as Mr. and Mrs. – not first names.
-Assessment must be in ARIAL 10 font
-Do not delete any section from the template
-Do not add any tables, headings, or make any formatting changes to the template.
-Do not type your assessment in the Guide, use the template provided
-Check boxes and headings/information that are in Italics will not appear in the Template, but are included
here for the purpose of guiding your assessment.
-Do not include Social Security Numbers within this assessment
General Information
Home Phone Number: do not leave blank, do not put N/A unless they don’t have a home phone
Work Phone Number(s): do not leave blank, do not put N/A unless they don’t work, can put refused to provide
Cell Phone Number(s): do not leave blank, do not put N/A unless they don’t have a cell phone
Directions to home: do directions from Dallas, Fort Worth, or Abilene not from your home
Identity of household members
Include the following in paragraph format. One paragraph for each current household member (includes the
child(ren) to be placed—note if not yet placed in the home) Answer ALL of the questions below for each person,
regardless of their age (i.e. Marriage, Military History).
Name (include maiden name if different and any other names used currently or previously)
Race of potential kinship caregiver(s)
Ethnicity (Hispanic or Non-Hispanic) of potential kinship caregiver(s)
Gender
Date of birth
Place of birth of potential kinship caregiver(s) including city, county, state and country
Citizenship/immigration status of potential kinship caregiver(s)
Physical description including: estimated height and weight, hair and eye color
Marital Status
Relationship to child (if not related by blood, then note how they know the child(ren))
Religion of potential kinship caregiver(s)
Military history
Highest level of education achieved
Primary language spoken (include any other languages spoken)
History of residence (document the length of time spent at each residence for the last 10 years, including street
address city and state). If all household members have the same residential history you can just write it once at
the end of this section, rather than writing it for each person.
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Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
Example: Samantha Nicole Sample (maiden name Smith, AKA “Sammy”), is a White, Non-Hispanic female.
Mrs. Sample was born on 01/01/1975 in Austin, Travis County, Texas, USA. She reports that she is a United
States citizen by birth. Mrs. Sample reports to be 5’4” tall and weighs approximately 140 pounds. She appears to
have light blue eyes and light brown, should-length, curly hair. Mrs. Sample reports that she is married to James
Anthony Sample. Mrs. Sample is the long-time friend of Cindy Jones, the mother of John Jones, the child in
consideration for placement. Mrs. Sample reports that she is a Christian and attends a non-denominational
church. She reports no military service history. Mrs. Sample reports that she graduated from Austin High School
in May 1994 and attended some courses at Austin Community College, but did not complete a degree or
certification program. Mrs. Sample reports that English is her only spoken language. Mrs. Sample reports that
she has lived at 301 Main Street, Austin, Texas 12345 since June 2004. Prior to this residence, she lived at 123
South Street, Dallas, Texas, 23456 from June 2002 to June 2004, and 456 West Street, Fort Worth, Texas, 56789
from August 2000 to June 2002.
Identify children to be placed (include information on each child)
Name
Date of Birth
Gender
History of residence (You do not necessarily need to have specific addresses if they are not available)
Citizenship/immigration status
Example: John Mark Jones is a male child born on 9/12/00. It is reported that before coming into care, John
resided with his biological mother in Austin, Texas in an apartment complex in South Austin and he has lived at
this residence since birth. It is reported that John Jones is a United States citizen by birth.
*if the child(ren) to be placed are already in the home follow the example: John Mark Jones was placed in the
home on 12/17/11. Please see the Identity of household members for further identifying information.
Summary of contacts
Date each individual contacted
Name of each individual contacted
Type of contact (phone, home visit, individual interview, couple interview, family interview, face to face, etc),
Location of contact (if applicable)
Example:
9/3/09 – Lisa Singleton – phone contact to schedule home visit, by S. Covenant
9/4/09 – Lisa Singleton, Jay Singleton, Kameron Singleton – Singleton home visit to conduct individual, couple
and family interviews, by S. Covenant.
9/5/09 – Lisa Singleton – phone contact unsuccessful for follow up information, by S. Covenant. No answer, left
voice message.
9/5/09 – Lisa Singleton – phone contact made for follow up information, by S. Covenant
*NOTE: do not list references here, including adult child contact
*Make sure to note that the Kinship Manual was given (in person, or via e-mail)
*Make sure to note that the Release of Information was signed if it was not provided within the referral packet
Safety
Issues identified in the risk assessment
Complete the Risk Assessment form which is applicable for all caregivers in the home and should also include the
child being considered for placement, regardless of whether or not they are already in the home. Have the
following statement “A Risk Assessment was completed by (your name and credentials) on (date). There
appears to be (i.e., no risks, some risks, no significant factors, significant risks, etc.) indicated based on the
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
written documentation provided by TDFPS at the time of this referral, face-to-face interviews and observations
during the home assessment, and reference reports.” Then summarize the risks—items marked “yes” on the risk
assessment form (do not write the questions from the Risk Assessment form and do not include the reference
codes from the Risk Assessment Definitions).
Address the relevant background information
The mitigating factors (factors that make the issue less severe) regarding the incident(s),
Any efforts at rehabilitation that have been undertaken
Any other issues relevant to explaining whether the placement is safe in light of the risk and safety-related
concerns.
Motivation
Define the relationship and the purpose for this assessment. (Example: Mrs. Sample is the long-time friend of
Cindy Jones, the mother of John Jones, the child in consideration for placement. She has always considered
herself to be his godmother (although not formally named as such) and is committed to ensuring that John has a
safe and stable home life, if his mother is not able to provide appropriate care for him.)
Kinship caregiver’s understanding of why child(ren) was removed from the home:
Explain whether kinship caregiver understands why the child(ren) was removed from the home (Do NOT tell
the family why the child(ren) were removed). If they do not know why the children were removed, then what do
the kinship caregivers believe was the reason for the child(ren) removal?
Document CPS reported reasons for why the child was removed.
Note any disparity between CPS reported reasons and the family’s believed reasons for placement.
Kinship caregiver’s feelings and attitudes toward the child(ren)’s parent(s) and other family members:
Has caregiver previously witnessed or become aware of child’s abuse? What was their response upon learning
of abuse?
Document caregiver’s feelings and attitudes towards birth parents and other family members. Are they
supportive of the parents? Angry, compassionate, fearful, etc? Do they believe abuse occurred as reported by
CPS? What is their opinion of the parents and view of abuse overall?
Do they feel confident in their ability to keep the child(ren) safe?
Do they anticipate any negativity or pressure from the birth parents and other family members?
Will they succumb to any pressure from the birth parents and other family members?
Kinship caregiver’s initial reasons for wanting the child(ren) placed in the home:
Explain what made the kinship caregiver decide they wanted the child(ren) placed in the home.
Include how long they are willing to keep child – temporary or long-term?
Kinship caregiver’s feelings and attitudes about the potential for placing the child(ren) in their home:
Does the kinship caregiver feel ready/able/willing to add additional child(ren) to home?
Do they feel able to manage more children financially and in regards to their room/space available and
time/managing schedules?
What are their greatest concerns? How are they managing these concerns? Are there any reports or signs tha
the potential caregiver is feeling anxious or overwhelmed about the placement?
How do they feel about being able to meet any special needs of the child(ren)?
Describe the kinship caregiver’s understanding of and support of the permanency plan.
What do they believe the CPS plan for the child is?
Are they willing and able to assist CPS in making sure the child is available for all CPS services (i.e., visitation
with the biological family).
Are they willing and able to provide care for the child throughout the CPS case?
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Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
History of alcohol and drug use of kin caregiver
Discuss kinship caregiver’s history of drug or alcohol use, if any:
History - Be specific with what and when? Even if just experimentation years ago.
Drinking to become intoxicated?
Include current usage of drugs and/or alcohol. How often (includes occasional drinking)? Where is alcohol
stored in home?
If none, write “[Caregiver’s name] reported no history of drug use or alcohol abuse.” Then write N/A for the
following sections (do not leave blank).
Discuss kinship caregiver’s efforts toward rehabilitation, if any:
Drug or alcohol treatment? When? How long? Was it successful?
**If they have used drugs or alcohol, but have not participated in rehabilitative activities, write as such.
If kinship caregiver reports a history of alcohol and drug use, assess kinship caregiver’s ability to provide a safe
environment for children:
Write your assessment and justify your opinion of safety issues related to drugs and alcohol.
History of child abuse/neglect of kin caregiver
Describe kinship caregiver’s history as a victim of child abuse (physical and sexual) and neglect, if any:
Who?
When?
What type of abuse?
How long did it occur?
By whom?
If none, write “Caregiver reported no history of abuse or neglect as a child.” Then write N/A for sections
following this question.
Discuss the kinship caregiver’s efforts toward rehabilitation, if any:
Therapy? Support groups? Do they feel they’ve been able to move through these difficult issues? Why and
how?
**If they have experienced abuse or neglect, but have not participated in rehabilitative activities, write as such.
If kinship caregiver was a victim of child abuse and/or neglect, assess his or her ability to provide a safe
environment for children:
Write your assessment of whether or not they’ve successfully resolved abuse issues. Substantiate your
assessment, using examples when possible. Describe how they will be able to keep child safe.
Abuse/Neglect and criminal history checks
**ask if any household member ever lived outside of Texas
**Criminal and/or CPS history of anyone who lives in the kinship caregiver’s home who is 14 years of age or
older:
**Very important in this section to just state the facts – no recommendations, even about potential bars.
**Obtain information from referral packet AND caregiver report. Document (for each individual in home age 14
and older) the date of check, did it return clear, and if not write what it listed as the offense, and date of offense.
**Example: The Criminal history check that was completed for Mary Jones on 3/23/2010 indicated “no hit
returned” or document the offense, and the date of the offense. The FPS check that was printed for Mary Jones
on 3/20/2010 indicated “no investigation history” or document the allegation, date of each allegation and findings.
**If no background check, list this as well so the reader knows we have not received a background check on an
individual in the home – including out of state checks that should be completed on caregiver. Note all efforts to
obtain/begin background check for this person.
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Form 6588ins
August 2011
Covenant Kids Kinship Home
Assessment Instruction Guide
**If someone is found in the home during the home visit, age 14 and older, and we either didn’t know they were
staying in home or do not have a criminal check for them, call or email the CPS worker as soon as possible with
the individual’s information so CPS can conduct a check. Then document in this section that it was requested
from CPS.
CPS and/or criminal history that operates as a potential bar, if any:
Do not make a recommendation as to whether or not this presents a potential bar to placement. Just restate
criminal offense and indicate that “it appears that this offense may serve as a bar for kinship placement and foster
and/or adoptive placement.” Etc.
*any questions about the consequences of CPS or criminal history, must be discussed with the CPS supervisor before the
home assessment is completed.
*the tables below are for reference
The Effect of a Criminal History on Kinship Placements
Category
1
Type of criminal conviction
Texas Penal Code Offense
A felony conviction of any of
the following (see descriptions
of offenses):
 Criminal Solicitation of a
Minor, Title 4, §15.031
 Offenses Against the Person,
Title 5
 Offenses Against the Family,
Title 6
Effect on Kinship Placement
Placement is not made.
Exception:
The child may be placed, only if:
 extraordinary circumstances exist; OR
 compelling justification is presented; AND
 placement is approved through the regional
director as described in 6322.37 Place a
Child With a Kinship Caregiver After All
Prerequisites Are Met
Effect on Eligibility
as a Foster or
Adoptive Home
Permanently
barred from
approval as a foster
or adoptive home.
Can never:
 be approved as a
foster or adoptive
home; or
 receive adoption
assistance.
 Robbery, Title 7, §29.02
 Failure to Stop or Report
Aggravated Sexual Assault
of a Child, Title 8, §38.17
 Stalking, Title 9, §42.072
 Public Indecency, Title 9;
Chapter 43
Federal Law or Other States
A felony conviction of any
substantially similar offense
under federal law or the laws of
another state
2
A drug-related felony conviction
Revised 01.16.2012-tj
Placement is not made until a risk evaluation is
completed by the regional program for foster
and adoption home development (FAD) because
the conviction may prevent the potential kinship
home from being verified as a foster home or
approved as an adoptive home.
Exception: If extraordinary circumstances exist
or compelling justification is presented and
approval to proceed with a home assessment is
given by the program director.
Absolute 5-year
bar
Barred for 5-years
from the date of
conviction
A home may or may
not be approved
pending the outcome
of a risk evaluation
performed at time of
approval.
Texas Dept of Family
and Protective Services
Form 6588ins
August 2011
Covenant Kids Kinship Home
Assessment Instruction Guide
3
Other felony conviction (A
felony conviction that occurred
within the past 10 years for an
offense other than one of those
listed in Category 1 of this table)
Placement is not made until a risk evaluation is
completed by the regional program for foster
and adoption home development (FAD) because
the conviction may prevent the potential kinship
home from being verified as a foster home or
approved as an adoptive home.
Exception: If extraordinary circumstances exist
or compelling justification is presented and
approval to proceed with a home assessment is
given by the program director.
Possible bar
The home may or
may not be
approved, pending
the outcome of the
risk evaluation
performed at the
time of approval
4
A misdemeanor conviction for
any of the offenses listed in
Category 1 or for a drug-related
offense
Placement is not made until a risk evaluation is
completed by the regional program for foster
and adoption home development (FAD) because
the conviction may prevent the potential kinship
home from being verified as a foster home or
approved as an adoptive home.
Exception: If extraordinary circumstances exist
or compelling justification is presented and
approval to proceed with a home assessment is
given by the program director.
Possible bar
The home may or
may not be approved
pending the outcome
of the risk
evaluation
performed at the
time of approval
5
A conviction involving deferred
adjudication, if the applicant has
not successfully completed
probation
Placement is not made until a risk assessment is
completed by the regional program for foster
and adoption home development (FAD) because
the conviction may prevent the potential home
from being verified as a foster home or approved
as an adoptive home.
Exception: If extraordinary circumstances exist
or compelling justification is presented and
approval to proceed with a home assessment is
given by the program director.
Possible bar
The home may or
may not be approved
pending the outcome
of the risk
evaluation
performed at the
time of approval
Offenses From the Texas Penal Code
Many of these offenses may be misdemeanors or felonies, depending on the specific conviction or indictment.
Shown in parentheses are the previous titles for an offense, or the titles of a similar offense.
Title 4 §15.031. Criminal Solicitation of a Minor
Murder
Title 5 Offenses Against the Person
Coercing, Soliciting, or Inducing Gang Membership
Capital Murder
Aggravated Assault
Manslaughter (Voluntary or Involuntary)
Aggravated Sexual Assault (Aggravated Rape, Aggravated
Sexual Abuse, or Rape of a Child)
Criminally Negligent Homicide
Injury to a Child, Elderly Individual, or Disabled
Individual
Unlawful Restraint (False Imprisonment)
Abandoning or Endangering Child
Kidnapping
Deadly Conduct (Reckless Contact)
Aggravated Kidnapping
Terroristic Threat
Unlawful Transport
Aiding Suicide
Indecency With a Child
Tampering With Consumer Product
Assault
Harassment by Persons in Certain Correctional Facilities
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
Title 5 Offenses Against the Person (continued)
Sexual Assault (Sexual Abuse or Sexual Abuse of a Child) Public Lewdness
Homosexual Conduct
Improper Photography or Visual Recording
Indecent Exposure
Leaving a Child in a Vehicle
Title 6. Offenses Against the Family
Enticing a Child
Prohibited Sexual Conduct (Incest)
Interference With Child Custody
Sale or Purchase of Child
Agreement to Abduct From Custody
Criminal Nonsupport
Advertising for Placement of Child (Solicitation of a
Child)
Violation of Protective Order or Magistrate’s Order
(Violation of Court Order)
Violation of Protective Order Preventing Offense Caused by Bias or Prejudice
Title 7. Offenses Against Property, Chapter 29
Title 8. Offenses Against Public Administration
Failure to Stop or Report Aggravated Sexual Assault of a Child
Stalking
Title 9. Offenses Against Public Order and Decency, Chapters 42 and 43
Prostitution
Aggravated Promotion of Prostitution
Promotion of Prostitution
Compelling Prostitution
Obscene Display or Distribution
Obscenity
Sexual Performance by a Child
Possession or Promotion of Child Pornography
Employment Harmful to Children
Sale, Distribution, or Display of Harmful Material to Minor
Title 10, Chapters 46 and 49. Offenses Against Public Health, Safety, and Morals
Making a Firearm Accessible to a Child
Public Intoxication
Possession of Alcoholic Beverage in Motor Vehicle
Driving While Intoxicated
Flying While Intoxicated
Boating While Intoxicated
Assembling or Operating an Amusement Ride While
Intoxicated
Intoxication Assault
Intoxication Manslaughter
Enhanced Offenses and Penalties
Health and Safety Code, Chapter 481, Subchapter D. Texas Controlled Substance Act
These offenses include, but are not limited to, the delivery, manufacture or possession of a controlled substance.
Concerns:
Document specific concerns generated from the outcome of background checks. Any concerns about caregiver
having child placed in home.
Does anyone’s criminal/CPS history pose a concern for them being a caregiver for child? Describe.
If there is a criminal/CPS history but there are no concerns state that there are no concerns regarding their
criminal/CPS history.
Background issues:
Individual’s explanation of circumstances surrounding the criminal/CPS offense.
If caregiver has ever lived outside state of TX as an adult, document here “Out of state criminal checks have
not been provided.”
Document if the checks were requested, from whom and the date requested.
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
Mitigating factors:
Address any sentencing that was court ordered per the criminal background report or by report of the caregiver.
This would include services such as probation, parole, fines, and incarceration.
Include length of time served as well.
Rehabilitation:
Address treatments such as drug rehab, AA, anger management, group therapy, church or religion, etc. This
would include more therapeutic type treatments.
**If they have a criminal or CPS history, but have not made any efforts towards rehabilitation, write as such.
Any other issues relevant to why the placement should be approved:
Ask the family why, despite criminal history, they believe they should be approved for placement. This is not
your recommendation, but a report on family’s reasoning for why they believe they should be approved for
placement. Write as such.
Caregiver’s future desires with respect to the placement:
If the caregiver has criminal/CPS history, use this section to document if they desire to provide short term and
long term care and adoption.
Note that you explained that approval to foster or adopt or be eligible for any kinship financial assistance or
Permanency Care Assistance also depends on whether the caregiver has disclosed all relevant information to
DFPS and on whether a CPS or criminal history emerges follow approval as a kinship home.
Content of discussions, including the caregiver’s reaction:
Document the content of the discussions in regards to criminal history and possible effect of criminal/CPS
history on their eligibility to foster, or adopt or be eligible for any kinship financial assistance or Permanency Care
Assistance, as well as the caregiver’s reaction to this discussion.
Family Relationships (Including history of family violence)
Previous relationships:
Previous significant relationships and/or marriages.
Describe when they met, courtship, decision to marry, date married.
If applicable discuss when/how/why it ended? How any issues were resolved?
Be sure to include info on any domestic violence within each relationship noted.
Note any children from previous relationships.
*If no history of significant relationships, state as such.
Current relationships (married couple):
State the marital status.
When they met, how long they dated, date of marriage.
Describe applicants’ interactions as husband and wife/couple.
Note whether or not they have experienced domestic violence in this relationhip.
Discuss any separations or marital counseling.
Address decision making processes (including financial decisions) and how they handle disagreements.
Discuss affects of adding a child to the home.
Describe strengths of marriage, weaknesses and needs.
Describe the emotional support systems each spouse has outside of the relationship.
Note your observations and assessment of stability of marital relationship.
*If not in a significant relationship, state as such.
Couples with children:
If a couple is interviewed that has children that do not live in the home, whether the child(ren) reside with another
parent or if they are grown adults, complete this section to address the caregivers parenting abilities, beliefs, etc.
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
Document names, ages and location of all children.
Describe couples interactions as parents.
Do they share parenting responsibilities, or one primary caregiver?
How do they support one another as parents?
Discuss how parenting decisions are achieved.
Do they agree or differ in discipline views?
How do they resolve disagreements?
Any issues of possessiveness, excessive control?
Include relatives’ view of and feelings about themselves as parents.
Describe the relatives’ expectations of their children and if the expectations are realistic.
Single parents:
If single adult is interviewed that has children that do not live in the home, whether the child(ren) reside with
another parent or if they are grown adults, complete this section to address the caregivers parenting abilities,
beliefs, etc.
Document names, ages and location of all children.
Discuss support system.
Describe significant relationships with both men and women.
Include feelings about themselves as a parent.
Describe whether the caregiver has realistic expectations for his or her child(ren) and the child(ren) that may be
placed in the home.
Do they date currently?
Describe relationship and dating partner.
How often do they see each other?
Will the child be exposed to the dating partner? How often?
Children:
*Interview any children living in the home and in the care of the kinship provider age three and older. If the child is
under the age of three years, observe the child’s interactions with the caregiver.
*Write an individual paragraph for each child in the home (does not include adult children who are outside of the
home). Begin with name, age, how and when they were interviewed. Describe the child.
*You must interview each child in the home (does not include adult children).
Ask each child about discipline, rules of the home, and their perception of the discipline in the home (is it harsh,
abusive, or fair).
Each child’s feelings towards the family’s decision to provide care to a relative child?
Report your perception of each child’s responses to questions, their support of child coming to the home, and
summarize the relationship with the parents. What is their parents’ perception of their support of child coming to
the home and their relationship with their child?
Describe your observations of interaction and relationship between child and the kinship caregivers.
Other household members:
Identify other household members
Discuss any other household member, who are they, are they there full or part time. If they are an adult child of
the caregiver--note here that they are another household member and then state that their individual interview is
located in the Reference section.
Example: Mary Smith is Mrs. Smith’s 24 year old daughter. She lives in the residence full-time. Please see
Reference section for individual interview.
Include results of criminal check if over 14 yr.
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Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
Describe interview with the individual. Are they supportive of kinship placement?
Discuss your observation of interaction between individual and caregivers/parents in home.
Family Functioning
Family rules and boundaries:
Discuss expectations, responsibilities, division or labor in home.
Discuss privacy, nudity and boundary issues within home.
Will this change any when child comes to home?
How family members handle stress and express negative feelings:
What makes them stressed (provide examples)?
How do they relieve stress? Be specific and include examples that support what they report.
Kinship caregiver’s home:
Give overall description of home (i.e. single story, three bedroom, two bathroom home).
Discuss general cleanliness and any clutter.
Address the potential kinship caregiver's ability to provide a safe home environment, and any pertinent issues
noticed (positive and negative; provide examples).
Describe sleeping arrangements
Do they have adequate space for children to play both inside and outside of the house
If no accommodations for child, describe caregivers plan to make room/storage available.
Give your overall assessment of safety of home. List any concerns.
Safety, related to child(ren)’s issues:
Discuss kinship caregiver’s understanding about any safety needs the child may have and how kinship
caregiver will deal with those issues.
Explore ability to provide protection to the child from parents or other relatives who may pressure them to return
the child to the parents or relative.
Explain how the caregiver plans to keep the child safe.
Report your assessment of safety issues and note any concerns.
Discipline:
Discuss relative’s view on parenting and child discipline and care.
Describe current methods of discipline if children in home.
If current practices are incompatible with DFPS policies, how do they plan to reconcile their practices?
Include applicant’s ability to support DFPS policy.
Note that the DFPS physical discipline policy was discussed with family and if the family will be able to comply
with/support the policy.
Child-care knowledge:
Discuss any child care experience.
Address caregiver’s expectations of the child(ren) to be placed. Are the expectations realistic?
Include expectations and examples about school performance, problematic behaviors, social skill delays,
educational difficulties, medical needs (how would the caregiver handle these issues?).
Is caregiver equipped and/or willing to deal with such issues?
Are their expectations flexible?
Are they available and willing to transport to any necessary appointment or meeting?
Child management:
Assess the caregiver’s ability to manage behavior of children who have been sexually or physically abused
and/or neglected in general.
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
Explore caregivers’ abilities to manage specific behaviors such as sexual acting out, aggression, abusive
language, etc. (If you know child under consideration is exhibiting specific behaviors, pose certain scenarios to
the caregiver, without breaking confidentiality, to explore whether or not they would be willing/able to handle those
specific behaviors.)
Remember, if the caregiver has had access to the children being placed, they have been exposed to children
who have been abused and/or neglected.
Permanency
Child(ren)’s involvement with the kinship caregiver:
Past involvement/relationship with the child(ren)
Current involvement/relationship, including any recent contact with the child(ren).
If the child is already placed in the home, include their stated feelings about the caregiver.
Kinship caregiver motivation and support of the permanency plan:
Reasons why caregiver desires to provide a home for child.
Length of time they anticipate caring for child, temporarily or permanently and how this compares with the goals
of DFPS. Report both the caregiver’s and your perceptions. And, report what the caregiver hopes/wants to be the
timeframe and outcome of the placement.
Explore caregiver’s attitude toward parental visitation and contacts, including willingness to cooperate with
visitation, case plans, and sibling contact if the child(ren) have siblings placed elsewhere. Also include their
willingness to support the permanency plan. Report relative’s perceptions.
Provide your assessment and perception of the caregiver’s sincerity and willingness to provide care despite
potential needs and behaviors and overall assessment of child care knowledge.
Kinship caregiver health (physical, mental and emotional of each caregiver):
Assessment of each caregiver’s physical, mental and emotional health in relation to their ability to parent the
child(ren).
Include any mental or physical health diagnoses, medications (prescription, over-the-counter, vitamins, herbal,
etc.) and hospitalizations (ever) related to mental or physical health.
Discuss any disabilities(if they don’t have disabilities then state as such), adjustment to the disability and any
limitations the disability may impose on their ability to provide safety, permanency and wellbeing to the child(ren).
Well-Being
Information about children to be placed:
Write a paragraph for each child being placed discuss and begin with the name, age, and how the information
was obtained:
Child’s placement history
Health status (any medical needs and ongoing health care required)
Child’s level of success in school (include academic performance and behavior issues). If the child is not
school aged, discuss any other behavioral or social issues.
Address caregiver’s ability to meet medical/dental, therapeutic, social, and academic issues of children being
placed
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
Children who have been physically, sexually abused and/or neglected:
Address caregiver’s sensitivity to and feelings about children who have been abused or neglected.
Include their understanding of how these issues and feelings will affect the children
and their own care towards the child.
Address the caregiver’s ability to help the child(ren) who have experienced abuse and neglect.
*Remember, if the caregiver has had access to the children being placed, they have been exposed to children
who have been abused and/or neglected, even if they don’t think that they have experience/exposure.
Financial situation
For each caregiver, Identify employment history, annual income, monthly NET (take-home) income, and
expenses. Assess and note their ability to manage money.
Include the following list of expenses for all studies: If the relative does not have some of the expenses listed
below, please do not include.
Mortgage:
Home Insurance:
Car Notes:
Vehicle Insurance
Gas/Water Utility
Electricity
Phone/Cell Expenses
Credit Cards
Church Giving
Medical Insurance
Groceries
Other Expenses (i.e. child support)
Report the total monthly net income, total monthly expenses and the total monthly income minus total monthly
expenses to help assess the caregiver’s ability to manage finances and determine if other resources may be
needed.
Discuss resources that may be available that could support the child( for example, child support, Medicaid,
TANF, and the support of other family members). Is relative able to seek resources if unaware of currently
existing services?
Discuss the caregiver’s ability to provide for the children being placed. Include discussion of available
resources.
Kinship caregiver’s support systems
Current accessible supports of relatives:
Is extended family and community supportive of placement?
Describe their location, their level of involvement, and how they will be supportive.
Explain the extent to which the caregiver will use identified family and community
supports to meet needs of child(ren).
Needed supportive services:
Identify services that may be needed to support the care of the child (i.e. day care, summer care, tutorials,
therapies, etc.)
What supports does the kinship caregiver have available now?
Discuss community services and resources kinship caregiver will need to locate.
To what extent will the caregiver use family & community supports identified to meet the needs of the children?
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Form 6588ins
August 2011
References
Document five references:
*Must have at least 2 relative and 3 non-related (In addition to the adult children of the potential caregiver)
*List name, date of contact, method of contact, relationship to caregiver (if it is a relative, how are they related),
who contacted.
*List all references provided – even if unable to contact
Example:
1: Sallie Jo Squizzle – friend – phone interview by S. Covenant, 9/15/11
2: Jamie Pinkerton – maternal aunt – phone interview by S. Covenant, 9/20/11
3: Tommy Noshow – neighbor – unable to contact on 9/15/11 or 9/17/11. A message with contact information and
a request for a return call was left each time.
4:
5:
Summary of references from kinship caregiver’s adult children:
*Interview all adult children, including the alleged perpetrator of abuse, unless otherwise notified in the CPS
referral, in which case, document the request for no contact.
*List all adult child(ren) & age 12 + children who live elsewhere—even if unable to contact
*List name, date of contact, method of contact, relationship to caregiver, who contacted.
Example:
1: Angie Sibling – daughter of Mr. and Mrs. Sample – phone interview by S. Covenant, 9/16/11
2: James Sibling – son of Mr. and Mrs. Sample – unable to contact. S. Covenant attempted to contact by
telephone on 9/15/11, 9/16/11, 9/18/11 at varying times of day. S. Covenant confirmed the telephone number
with Mrs. Sample on 9/17/11 and requested her assistance with encourage a return call prior to submission of this
assessment.
Summarize positive statements by adult child(ren) & age 12 + children who live elsewhere noting whether or
not they provided positive reference for parent and support of placement. Discuss parenting style, abuse or
neglect, discipline, contact today. Indicate which reference made which statements, and, when possible, use
direct quotes.
Summarize concerns raised by the adult child(ren) & age 12+ children who live elsewhere noting whether or
not they provided concerns regarding parent(s) and support of placement. Discuss parenting style, abuse or
neglect, discipline, contact today. Indicate which reference made which statements, and, when possible, use
direct quotes. Address all concerns.
Summary of positive references:
Summarize in one paragraph all of the reference received and statements that are positive. Indicate which
reference made which statements, and, when possible, use direct quotes.
Summary of negative references:
Summarize any negative reference received. Indicate which reference made which statements, and, when
possible, use direct quotes. Address all concerns.
Note here any references UNABLE to contact and describe unsuccessful attempts.
Summary of Kinship Caregivers Strengths and Concerns
Summarize the strengths in paragraph form. May include but not limited to the following:

No drug/alcohol use or abuse presently or by history

Good physical health with no discernable issues or concerns
Revised 01.16.2012-tj
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide

Parenting experience; parenting skills (by your observation or by history)

Good communication skills

Cooperative, flexible

Cleared criminal background check, “no hits”

Adequate space within home indoor and outdoor

Clean and safe home environment

Financially secure; job stability

Familiar with child, strong relationship

Committed to protecting child from harm

Willing to comply with DFPS plan for ongoing contact and permanency

Strong support system

Ability to seek and secure community resources

Education level

Experience in caring for specific medical, developmental, behavioral or therapeutic needs the specific
child may experience

Realistic expectations

Nurturing, supportive, loving, calm, patient

Ability to manage stress and pressure successfully and calmly

Desire

Willingness
 Commitment
Summarize the concerns in paragraph form. May include but not limited to the following:

Inadequate housing (too small, unsanitary, etc)

Chronic basic needs deficiency

Some environmental problems but correctable (pests, holes in wall, construction, clutter)

Questionable parenting skills (by observation or by history)

Unresolved abuse history

Unresolved separation or loss history

Mental health issues; mental illness untreated

Physical health concerns (illness, elderly, disability, etc)

Lacking financial resources; unemployed, job instability

Limited or ineffective communication skills

Anger control issues

Inexperience in managing behavioral/emotional issues specific to child in question

Inability to secure alternative childcare plans, day care and summer care

Limited intellectual functioning

Illiteracy—note why this would be a particular concern

Personal boundaries leading to family dysfunction, roles, behavior patterns

Due to age, inability to parent into adulthood; no guardian identified

Transportation difficulties

Poor coping skills
Revised 01.16.2012-tj
Form 6588ins
August 2011
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide

Pattern of unhealthy or harmful relationships

Inability to protect child (and explain how/why)

Does not believe abuse report

May not follow CPS rules for proper contact with parent, allowing unpermitted access

Lacking support and/or community resources

Drug and/or alcohol concerns

Inability to manage stress successfully

History of domestic violence; aggression

Destructive relationship patterns

Inability or unwillingness to find or use community resources

Questionable or negative criminal history results

No parenting experience

Destructive parenting patterns

Unrealistic expectations of children in care who have experience abuse/neglect

Unwillingness to manage identified behaviors, delays, disabilities, health issues of child

Missing background check on person living in the home

Uncooperative, unreasonable, defensive, hostile during interviews

Criminal and/or CPS history

Indication that individual does not live within the boundaries of society’s laws

Lack of desire

Lack of willingness

Lack of commitment
Revised 01.16.2012-tj
Form 6588ins
August 2011
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
Kinship Home Assessment Submitted by:
Signature Name of Home Screener, credentials—delete this and type
your name—for example-- Kelly Hill, MSW)
Date
Signature Name of Home Screener Contract Supervisor,
credentials—your supervisor’s name and credentials go here
Date
Revised 01.16.2012-tj
Form 6588ins
August 2011
Texas Dept of Family
and Protective Services
Covenant Kids Kinship Home
Assessment Instruction Guide
CPS Approver recommendations regarding placement
Signature Name of CPS Approver, credentials – DO NOT DO
ANYTHING TO THIS SECTION
Revised 01.16.2012-tj
Date
Form 6588ins
August 2011