Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Kinship Caregiver Home Assessment
Case Name: (Name of Person With the CPS Case)
Case ID Number:
Family Name: Name of Couple or Person Being Studied
Address
City, State Zip
County
CONTRACTOR’S INFORMATION
Assessment Provided by:
Phone:
Provider Email:
Subcontractor:
Phone:
Subcontractor Email:
CPS CASEWORKER, SUPERVISOR, PROGRAM DIRECTOR
Caseworker’s Name:
Supervisor’s Name:
Program Director’s Name:
Unit #:
Region #:
General Information about the case history and the caregiver under consideration
General Information
Home Phone Number:
Work Phone Number(s):
Cell Phone Number(s):
Directions to home:
Identity of All household members
Caregiver Information
Name:
Relationship to Child:
Gender:
Age/DOB:
Ethnicity:
Language:
Religion:
Marital Status:
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Citizenship:
Place of Birth:
Highest Level of
Education:
Height/Weight
Hair Color/Eye Color:
Branch of Military:
Dates of Service:
Discharge:
Child Household Members:
Name:
Relationship to Kin
Caregiver:
Relationship to Child:
Time Residing in Home:
Gender:
Age/DOB:
Ethnicity:
Language:
Religion:
Citizenship:
Place of Birth:
Highest Level of
Education:
Height/Weight
Hair Color/Eye Color:
Additional Adult Household Members:
Name:
Relationship to Child:
Gender:
Age/DOB:
Ethnicity:
Language:
Religion:
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Marital Status:
Citizenship:
Place of Birth:
Highest Level of
Education:
Height/Weight
Hair Color/Eye Color:
Branch of Military:
Dates of Service:
Discharge:
Identify children to be placed:
Name:
Relationship to Kin
Caregiver:
Gender:
DOB:
Age:
Location of Current
Placement:
School Information:
School District
Elementary School
Middle School
High School
Summary of contacts
Date
Location of Contact
Person Contacted
Type of Contact
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Safety
Kinship Caregiver's understanding of why child(ren) was removed from the home:
Kinship Caregiver's feelings and attitudes toward the child(ren)'s parent(s) and other family
members:
Kinship caregiver's initial reasons for wanting the child(ren) placed in the home:
Kinship caregiver's feelings and attitudes about the potential placement of a related child in their
home:
Kinship caregiver's future desires with respect to the placement:
Kinship Caregiver's history of alcohol and drug use or Present Use
Describe the kinship caregiver’s history or current use of drug or alcohol, if any:
Kinship Caregiver’s Tobacco Use
Kinship Caregiver's history of child abuse/neglect of kinship caregiver
Describe kinship caregiver’s history as a victim of child abuse (physical and sexual) and neglect, if any:
Kinship caregiver's rehabilitative activities, if any:
If kinship caregiver has a history of child abuse and neglect, assess kinship caregiver's ability to provide a
safe environment for children.
Findings from Caregiver's Abuse/Neglect and Criminal History Checks, if any:
Findings from Abuse/Neglect and Criminal History Checks for any household member over the
age of 14, if any
CPS or criminal history that operates as a potential bar, if any:
Concerns:
Background issues:
Mitigating factors:
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Rehabilitation:
Any other issues relevant to why the placement should be approved:
Effect of any CPS or criminal history of an individual in the home on the possibility of future adoption and
adoption assistance:
Effects of CPS and or criminal history of any individual in the home must be discussed with the kinship
caregiver. Below, describe that discussion, including the kinship caregiver's reaction:
Family Relationships
Family of Origin:
Previous relationships:
Current relationships (married couple):
Couples with children:
Single parent caregivers:
Children Currently in the home:
Other household members:
Family Functioning
Kinship caregiver health (physical, mental and emotional of each kin caregiver):
Family rules and boundaries:
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Handling Stress and Expressing Negative Feelings:
Kinship caregiver’s home:
Provide 10 year history of residences for the potential caregivers:
Dates At This Residence
Street Address & City
Reason For Moving
Situational Safety Issues:
Safety, related to child(ren)’s issues:
Discipline:
Child-care knowledge:
Child management:
Emergency Care Plan:
Financial situation:
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Net Monthly
Income:
Monthly Expenses:
Kin Caregiver #1:
Rent/Mortgage
Kin Caregiver #2:
Vehicle Payments
Other:
Car Maintenance & Fuel
Water
Electric
Gas
Telephone
Cable
Internet
Groceries
Medical Care Not Covered by
Insurance
Child Care Expenses
Health and/or Life Insurance
Premiums
Auto Insurance
Credit Card Payments (Total
Credit Card Debt:
)
Child Support Payments
Clothing
Personal Loans
Entertainment
Other Debts/Expenses:
Specify:
Other Debts/Expenses:
Specify:
Other Debts/Expenses:
Specify:
Total Monthly
Income
Total Expenses
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Permanency
Child(ren)’s involvement with the kinship caregiver:
Kinship Caregiver's plan to support the child(ren)'s permanency plan:
Well-Being
Children to be placed:
Dealing with children who have been physically, sexually abused and/or neglected:
Relative Support Systems
Needed supportive services:
Kin caregiver’s plan to use identified family and community supports to meet the needs of the children:
References
Name Of Reference
Date Of
Contact
Relationship To Subject
of Study
Location/Type Of
Contact
(Include Phone Number)
Summary of adult child references:
Summary of positive references:
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
Summary of negative references:
Issues identified in the Risk Assessment
Home Screener’s Recommendation
Based on the facts of the case, the observations and interviews conducted during the home study
assessment, as well as contacts made with collateral references, this interviewer identified the following
strengths and areas of concern regarding the potential placement:
Summarize the strengths:
Summarize any concerns:
Required Attachments:
 Signed Kinship Release of Information and Acknowledgement Form for all Household
Members age 18 or over.
 Completed Risk Assessment Form
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Texas Department of Family and
Protective Services
Form 6588
February 18, 2014
SIGNATURE PAGE
IMPORTANT: The content of this home assessment was developed based on limited contact with
the family and collateral contacts. Efforts have been made to verify the content of this study when
possible; however, due to the nature of the assessment, a considerable amount of the information
contained in this report was gathered through self report by the prospective caregivers. The
signature below reflects the submission of the Home Screener assessment ONLY and NOT the
approval of the respective home. This signature verifies the Home Screener has prepared the
home assessment in compliance with applicable State Standards.
Home Assessment Completed by:
Name of Home Screener, Credentials
Include License Number, if applicable:
Date
Home Assessment Reviewed & Approved by, if Applicable:
Name of Quality Managment Team Lead, credentials
Date
Delivered to Field Supervisory Staff, Date: ____________________
Reviewed by a DFPS/CPS Program Director or Designee: Date: ___________________
CPS Field Supervisory Staff Action:
I acknowledge that I reviewed this home assessment and identified concerns, if any. The
following steps will be taken to address identified concerns:
PLACEMENT APPROVED
PLACEMENT NOT APPROVED (Justification must be documented on Form 0699)
____________________________________________________________________________
CPS Staff Printed Name
CPS Staff Title
__________________________________________
Date: _________________
CPS Staff’s Signature
__________________________________________
CPS Program Director Printed Name
___________________________________________
Program Director Signature
Date: _________________
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