West Virginia Department of Health and Human Resources

Family Case Plan Evaluation

__________________________________________________________________
Family Name FACTS Case #

Worker Name

Date of PCFA:

Family Case Plan Evaluation Date:

Family members, treatment team members and/or safety service providers involved in the Family Case Plan Evaluation: 1. 2. 3. 4. 5. 6.

A. Caregiver Protective Capacity Evaluation

Caregiver #1: _________________________ 1. Identify what progress has been made toward enhancing caregiver protective capacities: Goal a. No Progress Minimal Progress Significant Progress Goal Achievement

Thoroughly justify the progress decision below:

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Goal b. No Progress Minimal Progress Significant Progress Goal Achievement

Thoroughly justify the progress decision below:

Goal c. No Progress Minimal Progress Significant Progress Goal Achievement

Thoroughly justify the progress decision below:

Goal d. No Progress Minimal Progress Significant Progress Goal Achievement

Thoroughly justify the progress decision below:

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2. Describe effectiveness of Family Case Plan activities, services and service providers used to meet the desired goals above.

Caregiver #2: _________________________ 1. Identify what progress has been made toward enhancing caregiver protective capacities: Goal a. No Progress Minimal Progress Significant Progress Goal Achievement

Thoroughly justify the progress decision below:

Goal b. No Progress Minimal Progress Significant Progress Goal Achievement

Thoroughly justify the progress decision below:

Goal c. No Progress Minimal Progress Significant Progress Goal Achievement

Thoroughly justify the progress decision below: 10-1-10

Goal d. No Progress Minimal Progress Significant Progress Goal Achievement

Thoroughly justify the progress decision below:

2. Describe effectiveness of Family Case Plan activities, services and service providers used to meet the desired goals above.

Repeat section 1and 2 if required for additional caregivers

B. Child Needs Assessment Evaluation

Child #1: _________________________

1. Child well-being needs identified during the Protective Capacities Family Assessment a. b. c. d.
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Status of treatment needs for children in the home and/or children returning to home through reunification (describe status of needs previously identified, any newly identified needs, and general statement of effectiveness of treatment services.)

2. Service: _________________________ Describe effectiveness of services and service providers used to meet or assist the parent in meeting the child well-being needs below.

Child #2: _________________________

1. Child well-being needs identified during the Protective Capacities Family Assessment a. b. c. d. Status of treatment needs for children in the home and/or children returning to home through reunification (describe status of needs previously identified, any newly identified needs, and general statement of effectiveness of treatment services.)

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2. Service: _________________________ Describe effectiveness of services and service providers used to meet or assist the parent in meeting the child well-being needs below.

Child #3: _________________________

1. Child well-being needs identified during the Protective Capacities Family Assessment a. b. c. d. Status of treatment needs for children in the home and/or children returning to home through reunification (describe status of needs previously identified, any newly identified needs, and general statement of effectiveness of treatment services.)

2. Service: _________________________ Describe effectiveness of services and service providers used to meet or assist the parent in meeting the child well-being needs below.

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Repeat section 1and 2 if required for additional children

C. Status of Change
1. Status of Motivational Readiness (Note where individual family members in relationship to the stages of change at the time of the Family Case Plan Evaluation. The stages of change are: Pre-Contemplation, Contemplation, Preparation, Action and Maintenance)

2. Identify and specifically describe currently existing/ enhanced caregiver protective capacities and discuss how existing caregiver protective capacities can influence change.

3. Describe potential barriers to meeting client goals and outcomes, including the relationship the client has with the Child Protective Services Worker.

4. Does the Family Case Plan and Safety Plan need to be revised based upon the results of the Family Case Plan Evaluation and Continuing Safety Analysis? Yes or No 10-1-10

If yes, thoroughly justify below and revise the Family Case Plan and/or the Safety Plan.

5. Does the Family Case Plan Evaluation and the results of the Continuing Safety Evaluation indicate that the child (ren) would be safe without CPS intervention? Yes or No If yes, complete questions 6 and 7. If no, proceed to section D. 6. Thoroughly describe the basis for the conclusion including the removal or diminished effect of the impending danger threat and /or the enhanced protective capacities that now fully control the impending threats below.

7. If the children are safe and the case is being closed, describe the formal and informal supports that can remain involved with the family following CPS Ongoing Case closure below. Also document clearly that outcomes have been achieved and goals have been achieved. If the outcome/goals have not been fully achieved describe how enhanced protective capacities (specific) and family strengths have combined to eliminate or control the impending danger threats.

D. Signatures
This plan will be reviewed every 90 days or when circumstances warrant. The next scheduled review will be on ____________________. The review will include the family, formal and informal safety service providers and the Department. At that time changes to the services may be made.

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CPS Social Worker_______________________________________Date__________________ CPS Social Workers Phone #_______________________________________________ Supervisors name and Phone #_____________________________________________ Parent/Caregiver_____________________________________Date______________________ Other Parent/Caregiver _______________________________Date______________________ Other Parent/Caregiver _______________________________Date______________________ Formal and Informal Service Provider(s) ___________________________________________________Date_____________________ ___________________________________________________Date_____________________

Supervisor approval: _________________________________Date_____________________

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