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Child Protective Services: Family Preservation
Social Services Manual Child Protective Chapter 2100, Section VII
September 2000 Page 1
CODES/REFERENCES
O.C.G.A § Section 15-11-190
O.C.G.A § Section 15-11-191
REQUIREMENTS
The Division of Family and Children Services (DFCS) shall initiate a Comprehensive
Child and Family Assessment (CCFA) for each child entering care via a referral to an
approved provider within one business day of the Preliminary Protective Hearing. The
CCFA shall comply with the standards as described at
http://dfcs.dhs.georgia.gov/support-services-program.
DFCS shall utilize DFCS staff or a state approved/contracted provider to complete the
CCFA.
DFCS shall collaborate with the Amerigroup Care Coordination Team (CCT) to ensure
each child entering foster care receives a Health Check within 10 calendar days of
entering foster care even if they have been seen by a doctor in the recent past. The
Health Check must be completed by a licensed medical provider and the dental
examination must be completed by a licensed dentist (See policy 10.11 Foster Care:
Medical, Dental, and Developmental Needs).
DFCS shall collaborate with the Amerigroup Care Coordination Team (CCT) to ensure
each CCFA includes a Trauma Assessment for each child five years of age and older.
As directed by the court, DFCS shall complete a social study concerning a child that has
been adjudicated as a dependent child. Each social study shall include, but not be
limited to a factual discussion of each of the following subjects:
1. What plan, if any, for the return of the child to his or her parent and for achieving
legal permanency for such child if efforts to reunify fail;
2. Whether the best interests of the child will be served by granting reasonable
visitation rights to his or her other relatives in order to maintain and strengthen
the child’s family relationships;
3. Whether the child has siblings under the court’s jurisdiction, and if so:
a. The nature of the relationship between such child and his or her siblings;
b. Whether the siblings were raised together in the same home, and whether
GEORGIA DIVISION OF FAMILY AND CHILDREN SERVICES
CHILD WELFARE POLICY MANUAL
Chapter: (10) Foster Care
Effective
Date:
August 2014Policy
Title:
Comprehensive Child and Family
Assessment (CCFA)
Policy
Number:
10.10
Previous
Policy #:
1006.1

the siblings have shared significant common experiences or have existing
close and strong bonds;
c. Whether the child expresses a desire to visit or live with his or her siblings
and whether ongoing contact is in such child’s best interest;
d. The appropriateness of developing or maintaining sibling relationships;
e. If siblings are not placed together in the same home, why the siblings are
not placed together and what efforts are being made to place siblings
together or why those efforts are not appropriate;
f. If siblings are not placed together, the frequency and nature of the visits
between siblings;
g. The impact of the sibling relationship on the child’s placement and
planning for legal permanence;
4. The appropriateness of any placement with a relative of the child;
5. Whether a caregiver desires and is willing to provide legal permanency if
reunification is unsuccessful.
NOTE: If thoroughly completed, the CCFA may be submitted to the court to meet the
social study requirement and shall include all the outlined components.
DFCS shall terminate the CCFA if a child returns home at the 10 day Adjudicatory
Hearing. The provider will be reimbursed for each completed portion of the CCFA
submitted within 10 calendar days of the cancellation.
DFCS and/or the CCFA provider shall attempt to engage all family/household members
in the CCFA process.
DFCS shall require providers to submit the completed CCFA to DFCS no later than 25
calendar days of the referral.
DFCS shall initiate the Supplemental Security Income (SSI) application process on
behalf of any child whose CCFA indicates the presence of mental or physical disabilities
within five business days of receiving the CCFA.
PROCEDURES
The Social Services Case Manager (SSCM) will:
1. Determine if the family and/or child have received any type of formal
assessments within the last 12 months (e.g., medical, social, educational, family
psychological, etc.). If so, determine which CCFA components will need to be
completed during the current placement episode. The assessor must collect the
past records and reports, assemble the information, and incorporate it into the
CCFA.
2. Determine if the CCFA will be completed by the SSCM or an approved provider.
If the latter, select a state approved provider.
3. Select a provider from the approved provider directory available at
http://dfcs.dhr.georgia.gov/fostercare and record the name of the provider on the
Needs and Outcome page in Georgia SHINES, the Statewide Automated Child

Welfare Information System.
4. Complete the Service Authorization Detail page in Georgia SHINES and submit
the referral to the selected provider within one business day of the Preliminary
Protective Hearing if the child remains in DFCS custody.
5. Notify the CCT of the referral to the CCFA provider within 24 hours of the
Preliminary Protective Hearing. The CCT will contact the DFCS Case Manager
regarding scheduling of medical/dental appointments and send the receipt of
medical/dental information for the assessment to the CCFA provider within 17
days.
6. Within 24 hours of the CCFA provider accepting the referral, provide written
notice of intent to complete the CCFA to the birth family and placement provider
outlining the family assessment process and introducing the selected provider.
7. Within two business days of the provider accepting the referral, make available
for review any background information on the child and parents. Obtain the
appropriate release of information prior to releasing protected health information
on the parents (i.e., HIPAA). Allow the provider to review the record with the
exception of the names of any reporters.
NOTE: Only DFCS staff may copy documents from a case record.
8. Collaborate with the CCFA Provider and schedule a Multi-Disciplinary Team
(MDT) meeting as part of the CCFA within 25 calendar days of a child entering
foster care. Include representatives from at least three professional disciplines
(e.g., public health, mental health, and education) as well as the child, his/her
parents, and their informal support team.
9. Provide the parents written notice of the MDT at least five business days in
advance of the scheduled meeting date.
10.Participate in the MDT meeting
a. Ensure the FTM/MDT recommendations concerning the child’s placement
setting, permanency plan, and service needs (including those of the family
and/or caregiver) are clearly documented.
b. Select reasonable, achievable goals/objectives that address the specific
behaviors or conditions that must be corrected for the child to be safely
returned to the parent.
11.Within five business days of receiving the final CCFA report and billing invoice,
review the CCFA information for quality and accuracy.
a. If the CCFA is incomplete or of poor quality, immediately return it to the
provider with specific information about what must be improved or
changed.
b. If the CCFA is complete and of acceptable quality, immediately approve
the invoice, submit to the supervisor for approval, then forward to regional
accounting for payment.
12.Make appropriate service referrals within five business days to address non-
emergency needs identified in the approved CCFA. Emergency needs require an
immediate service referral.
13.Initiate a home evaluation of any relative identified within the CCFA report as a
potential placement resource.

14.Submit a copy of the CCFA to the Juvenile Court within 30 days of a child
entering care along with the initial case plan.
If the SSCM (in lieu of a CCFA provider) completes a Family Assessment, the
assessment will include, but is not limited to, the following components:
a. Household Composition/Key Data
b. Prior Agency Involvement
c. Living Arrangements
d. General Financial Status and Employment History
e. Health of All Household Members
f. DHR Form 419, Background Information on State Agency Child
g. Marital Status
h. History of Criminal Activity (list existing or known information; a criminal
records check is not required)
i. Education Status
j. Relationship between Parent and Child
k. Family and Community Resources
l. Family’s Strengths and Needs
m. Summary, Conclusions, and Recommendations
The CCFA provider will:
1. Contact the applicable SSCM by fax or email within 48 hours of receiving the
referral to indicate whether or not the referral will be accepted or declined.
2. Make face-to-face contact with the birth family within two business days of
accepting the referral.
3. Collaborate with the CCT to obtain completed medical, dental, and trauma
assessment for inclusion in the completed CCFA report.
4. Provide written notice to the SSCM within five business days if unable to make
the required face-to-face contact within the designated time frame.
5. Engage all pertinent family members.
6. Explore all available sources of possible information about the family, including
making collateral contacts with individuals/agencies that know or have worked
with the family.
7. Observe family interactions, living conditions, behaviors, etc.
8. Review formal evaluations and treatment summaries (e.g., medical,
psychological, drug and alcohol assessments, etc.)
9. Attend court hearings, MDT and FTMs.
10.Submit completed sections of the CCFA within 10 calendar days of being notified
of the termination or cancellation of the CCFA.
11.Submit the completed CCFA within 25 days of the referral date.
12.Make additions/corrections to the CCFA recommended by DFCS.
If the CCFA is cancelled, the SSCM will:
1. Notify the provider (if applicable) and the CCT as soon as the decision is made to
cancel the CCFA. The initial notification may be made via telephone and followed
by written notification. The CCT must be notified via the Amerigroup GA families

360º DFCS Form.
2. Include the date of cancellation in the written notification (i.e., date of the
Adjudicatory Hearing returning the child).
3. Document the verbal and written notification of cancellation in the Contact Detail
in Georgia SHINES. Indicate the full name of the person(s) notified.
PRACTICE GUIDANCE
DFCS has multiple strategies for assessing the initial well-being of children entering
foster care and providing follow-up to ensure identified needs are addressed timely and
appropriately. Serious needs may require ongoing treatment long after the child returns
home or to another permanent living arrangement. The SSCM must engage
parents/caregivers at the time of removal, and each subsequent contact, to obtain a
complete picture of each child’s needs. The SSCM must be knowledgeable and
resourceful in utilizing and developing resources to enable children to achieve the
highest level of functioning possible. The CCFA is initiated following the Preliminary
Protective Hearing, if a child remains in DFCS custody. If the Preliminary Protective
Hearing is continued, the CCFA will be initiated after the conclusion of the extended
hearing. This is to avoid initiating a CCFA before the court has ruled that there is
sufficient evidence for the child to remain in foster care until the Adjudicatory Hearing.
Gathering Information
Explore all sources of possible information about the family that will assist in conducting
a family assessment. It may require obtaining a signed Authorization for Release of
Information form. Some ways of obtaining information include:
1. Consulting with the previous Case Managers, Supervisor or other DFCS staff
familiar with the family
2. Reviewing past CPS and Foster Care history
3. Making collateral contacts with individuals/agencies that know or have worked
with the family
4. Observing family interactions, living conditions, behaviors, etc.
5. Accessing reports and records generated from other agencies and/or other
professionals
6. Reviewing formal evaluations and treatment summaries (e.g., medical,
psychological, drug and alcohol assessments, etc.)
7. Obtaining any other source of information pertinent to the assessment process.
Family Engagement
The child and his/her immediate and extended family should be engaged in the
assessment process to gather as complete a picture as possible of the family. Family-
centered approaches such as a FTM are effective ways to involve the family in
assessment, planning and decision-making around the needs of the child. The
assessment information also assists judges, CASAs, citizen panels, and other providers
working with the child and family to gain a better understanding of the:
1. Parental capacities and child vulnerabilities

2. Degree of parent-child attachment and the child’s sense of belonging
3. Child’s extended family as a potential resource for support and/or placement of
the child
4. Family’s history and/or patterns of behavior (e.g., prior CPS involvement or foster
care placements, past experience with handling crisis, problems with addiction,
criminal behavior, etc.)
5. Strengths and resources which the family can engage
6. Core needs of the family which, at a minimum, must be changed or corrected for
the child to be safely returned within a reasonable period of time
7. Challenges impacting the success of a reunification permanency plan
8. Identified medical, emotional, social, educational and placement-related needs of
the child
Georgia Families 360˚
On March 03, 2014, DFCS transitioned from a standard fee-for-service Medicaid
program to a statewide Medicaid Care Management Organization (CMO) through
Amerigroup Georgia Managed Care Company. The transition impacted children in
DFCS custody and children receiving AA as they became members of a new program
called Georgia Families 360˚ which is separate from Georgia Families, the general
Medicaid program administered by the Georgia Department of Community Health
(DCH). Georgia Families 360˚ is designed to provide coordinated care across multiple
services and focus on the physical, dental, and behavioral needs of member children.
The program is designed to ensure each member has a medical and dental home,
access to preventive care screenings, and timely assessments. It also seeks to ensure
medical providers adhere to clinical practice guidelines and evidence-based medicine.
Amerigroup Care Coordination Teams (CCT) and Care Managers
Each Georgia Families 360˚ member is assigned to a regional Care Coordination Team
with a specified Care Manager. The CCT completes a Health Risk Screening (HRS) on
youth in care to identify medical and/or behavioral needs. They ensure each child is
assigned to a Primary Care Physician (PCP) and Primary Care Dentist so every child
has a medical and dental home. The CCT is responsible for coordinating the health
components of the Comprehensive Child and Family Assessment (CCFA), including the
initial physical examination, dental examination, and trauma assessment.
Care Managers are the primary partner of the SSCM for identifying and making referrals
for needed services. Care Managers ensure each youth has an individualized care plan
that addresses both physical and behavioral health needs. They work with community
agencies to ensure appropriate services are provided.
Any services not authorized by the CCT will not be paid for out of Medicaid. Therefore, it
is imperative that all medical/dental, behavioral health and developmental care be
coordinated with the CCT to avoid any uncovered expenses. See the COSTAR Manual
Section 3001 Family Foster Care Programs an explanation of the “Unusual
Medical/Dental” funding source for children who are not Medicaid eligible or who receive
a service not covered by Medicaid. For youth covered by other forms of Medicaid (i.e.,

Fee-for-Service) or health coverage, the SSCM should utilize known providers in the
community and contact the assigned Regional Well-Being Specialist for further support
or assistance.
Amerigroup GA Families 360º DFCS Referral Form
DFCS communicates with Amerigroup, Rev Max, and DCH utilizing the Amerigroup GA
Families 360° DFCS Referral Form. It is the primary means for communicating
information about a member in Georgia Families 360˚. The Amerigroup GA Families
360° DFCS Referral Form must be completed and sent to Amerigroup, Rev Max, and
DCH within 24 hours of a youth entering foster care. It should be completed thoroughly
to include demographic information, medical information, placement information, the
identified CCFA provider and other referrals (e.g., Babies Can’t Wait). The referral form
is also used to report updates such as placement changes, a youth exiting care, etc. If
there is information not available at the time of the initial referral to Amerigroup, submit
an Amerigroup GA Families 360° DFCS Referral Form (update) as soon as the
information is obtained. Accurate and timely communication with Amerigroup and Rev
Max is vital to the Medicaid eligibility determination and assignment of a CCT and
service providers. Important decisions regarding the assignment of primary care
providers and referrals are made based upon the information submitted on the referral
form.
Health Check
The initial Health Check assists in identifying a child’s medical, developmental, and
mental health needs and ruling out medical conditions. (See policy 10.11 Foster Care:
Medical, Dental, and Developmental Needs)
Children housed in Youth Detention Centers (YDC), not Regional Youth Detention
Centers (RYDC), are ineligible for Medicaid. Consequently, such children’s health
services will be provided by the YDC, including initial assessments required upon
entering foster care. Once the youth is released from YDC, the SSCM should update
Georgia SHINES to reflect the change in placement and submit an application to Rev
Max for Medicaid eligibility determination.
Trauma Assessments
Trauma can affect many aspects of a child’s life and may lead to secondary problems
that negatively impact safety, permanency, and well-being (e.g., peer relationships,
problems in school, health related problems).The Administration for Children and
Families (ACF), a federal agency in the Department of Health and Human Services, has
informed state child welfare agencies of the need to implement trauma-focused
screening, assessment and treatment for children in foster care. The emotional well-
being of our children is of the utmost importance and is directly correlated to their
ongoing safety and success of permanency plans. Children five years of age and over
are referred for a comprehensive trauma assessment after the completion of the
medication evaluation and after the results of the hearing and vision screening have
been received. The trauma assessment identifies all forms of traumatic events

experienced directly or witnessed by a child to determine the best type of treatment for
that specific child. In addition to the trauma history, trauma-specific evidence-based
clinical tools assist in identifying the types and severity of symptoms the child is
experiencing. Examples of evidence-based, trauma-specific clinical tools include:
1. UCLA PTSD Index for DSM-IV
2. Trauma Symptom Checklist for Children (TSCC)
3. Trauma Symptom Checklist for Young Children (TSCYC)
4. Child Sexual Behavior Inventory
The trauma assessment must provide recommendations and actions to be taken by
DFCS to coordinate services and meet a child’s needs. Behavioral health providers who
conduct a trauma assessment will provide a report which includes:
1. Trauma history, which informs the agency of information concerning any trauma
the child may have experienced or been exposed to, as well as how they have
coped with the trauma in the past and present
2. A standardized trauma screening tool
3. Summary and recommendations for treatment (if needed)
The inclusion of a trauma assessment as part of the CCFA does not mean there will not
be situations in which other specialized assessment (e.g., psychological evaluations,
psycho-sexual evaluations, psychiatric evaluations, neuropsychological evaluations,
substance abuse assessments or psycho-educational evaluations) will be warranted.
The decision to refer a child for additional assessments must be made on a case-by-
case basis in coordination with the CCT after an overall assessment of the child’s needs
has been completed. If it is determined that a psychological evaluation is needed, prior
authorization must be obtained from the CCT in order for Medicaid to pay for it.
Relative Care Assessment (RCA)
The CCFA may identify relatives that may be explored as placement or visitation
resources. With supervisory approval, a case manager may request a CCFA provider to
complete the RCA (See policy 10.5 Foster Care: Relative/Non-Relative Care
Assessment). The provider must follow the format and all procedures outlined in the
Placement of a Child section of Foster Care policy. The RCA must be requested as part
of the CCFA in order to utilize the CCFA funding source. Refer to the COSTAR Manual
Section 3006 Support Services manual for information regarding funding.
FORMS AND TOOLS
Amerigroup GA Families 360º DFCS Referral Form
Authorization for the Release of Information
COSTAR Manual Section 3001 Family Foster Care Programs
COSTAR Manual Section 3006 Support Services
SECTION I
FOREWORD

A. INTRODUCTION
A thorough understanding of the family is the foundation of all child welfare
interventions. The assessment process is ongoing and involves gathering facts,
observations and information about and from the family. Since assessment is an
ongoing process, the Social Services Case Manager (SSCM) continually reassesses
the family at each family contact, at every family meeting, during supervisory
conferences, judicial or citizen’s panel reviews, and administrative case reviews to
determine whether the family is making reasonable progress toward the permanency
goal. During the assessment process, information is analyzed and conclusions are
drawn about family strengths and needs. The SSCM gains a better understanding of
the family as a unique system. The assessment process provides insight into how
family members think, feel, behave, relate to others and respond to various situations,
including the removal of the child.
Assessment results are the foundation of the case plan. Assessment outcomes help to
guide staff in making sound decisions about the best placement for the child, the critical
service needs of the child and family, and the most viable plan for achieving
permanency. Initially, the assessment assists staff in making a prognosis regarding the
likelihood for reunification, which is the preferred option for achieving permanency when
safety can be assured.
A formalized assessment known as the Child and Family Comprehensive Assessment
(CCFA) is initiated soon after the child enters care. The child and his/her family, both
immediate and extended, are engaged in the assessment process. Family-centered
approaches such as Family Team Meetings and Multi-Disciplinary Team Staffings are
effective ways to involve the family in assessment, planning and decision-making
around the needs of the child. The Family Assessment is the foundation of the family
case plan and will also assist judges, CASA’s, Citizen Panels, and other providers
working with the child and family to gain a better understanding of the:
 Degree of parent-child attachment and where the child feels a sense of
belonging;
 Child’s extended family as a potential resource for support and/or the placement
of the child;
 Family’s history and/or patterns of behavior; e.g., prior CPS involvement or foster
care placements, past experience with handling crisis, problems with addiction,
criminal behavior, etc.;
 Strengths and resources from which the family can tap;
 Core needs of the family which, at a minimum, must be changed or corrected for

the child to be safely returned within a reasonable period of time;
 Probability of the child returning home or the likelihood of an alternative
permanency plan; and
 Identified medical, emotional, social, educational and placement-related needs of
the child.
Children entering care are at higher risk than the general population for delays and
disabilities. In addition, the trauma of placement can result in emotional distress and
trauma. Consequently, a comprehensive screening or assessment of the child and
family can have a positive life changing impact, if problems are identified and early
treatment interventions are implemented. Georgia DFCS Foster Care Program
designed the First Placement/Best Placement (FPBP) assessment procedures and
standards now known as the Comprehensive Child and Family Assessment (CCFA).
As required by Social Services Policy 1006 – Assessment and Permanency, a referral
for a Comprehensive Child and Family Assessment (CCFA) is made for every child
entering foster care as soon as the 72-hour hearing is held to detain the child in care. If
the child has received an evaluation in the previous 12 months, a Comprehensive Child
and Family Assessment is not required. A thorough and comprehensive Family
Assessment shall be completed within thirty days of the date of referral. The
assessment information will be used in developing case plans, determining the needs of
the child and family and in sharing with the court.
Children entering foster care will have a Health Check (Early and Periodic Screening,
Diagnostic and Treatment –EPSDT) within ten (10) days of the child’s placement in
foster care at the local health department or with an approved Health Check provider. A
list of approved Health Check providers is located at: www.ghp.georgia.gov. The Health
Check screen will assist in addressing medical, developmental, and mental health
needs of children entering foster care and rule out medical conditions, which may cause
problem behaviors, delays and disorders.
If the county determines the need for a Comprehensive Child and Family Assessment
(CCFA) for a child that has been in care for twelve (12) or more months, to assist in for
permanency planning for the child, the County Director must submit a written waiver
request to the Regional Field Director stating the reason the assessment is needed, the
length of time the child has been in foster care, and the child’s permanency plan.

CCFA Referral and Assesment Procedure
Child in care 7 days.
Within 24 hours of the provider’s acceptance of the referral, the
SSCM:
1. Sends a referral letter to the parent and caregiver
outlining the process of the CCFA and identifies the
CCFA provider. The CCFA provider receives a copy of
the letter.
2. Provides the provider with a Pre-Evaluation Checklist
with all applicable documents attached.
Within 9 days
of child
entering FC,
DFCS
facilitates the
1st Family
Team Meeting.
DFCS SSCM
schedules the date
and time of the Family
Team Meeting (FTM).
FTM must be held
within nine (9) days of
child’s placement in
FC.
DFCS SSCM
schedules the
date and time of
the Multi-
Disciplinary Team
Meeting (MDT).
MDT must be
held within 21
days of the
referral date.
Provider has 24 hours to
accept or decline the referral
via Form 1.
If the child remains in care following the 72-Hour Hearing,
a referral is made via Form 1, Referral for Assessment, to
an approved CCFA provider.
If the provider
declines the
referral, the
SSCM must
make another
referral.
Within two business days of accepting the referral, the
provider:
1. Must make a face-to-face contact with each family
member referred for services and present a picture
ID yourself and a copy of the referral letter.
2. Schedule a time to review the case record at the
DFCS office.
The Provider
schedules all
necessary
appointments
and provides
transportation
.
Within 10 days of the child entering FC, the child must have a Health Check via the Public Health
Department or with an “Approved Health Check Provider.” DFCS or the provider, if the service is
purchased, accomplishes this step.
Child in care 3 days

Within 30 days of the child being in care, the initial case
plan is submitted to Juvenile Court.
Within 21 days of the referral, the Provider will
facilitate the MDT meeting. Initial case plan is
completed.
Within 30 days of the referral, the Provider submits
final written report and an assessment invoice to the
designated county staff member. (Unless a waiver
was requested.)
Within 15 days of the
referral, if required, the
CCFA Provider may
request a waiver for up to
15 additional days to
complete the
assessment.
Five calendar days
before the MDT,
DFCS must send
notice ofthe
meeting, and the
intent to develop the
initial case plan to
the birth parent.
If the child is returned home at the 10 Day Hearing,
then the county may:
1. Cancel the CCFA and accordingly
compensate the provider for work
accomplished or
2. Continue the CCFA.

B. BASIC RESPONSIBILITIES Comprehensive Child and Family Assessment
(CCFA)
Children and families who have not been assessed when entering the foster care system in the past 12
months must be referred for a Child and Family Comprehensive Assessment. (Policy manual ref.
1006.1)
POLICY AND
PROCEDURES
CASE MANAGER'S
RESPONSIBILITIES
PROVIDER'S
RESPONSIBILITIES
INITIATION
The earliestpointof referral is within
24 hours following the 72-hour
hearing at which time the court
determines thatthe child will be
retained in DFCS custody.
Assessmentservices are initiated.
(DFCS Social Services Policy Manual
ref. 1006)
Note: Providers of services mustbe
licensed and meetthe Standards for
the CCFA established bythe Division.
Only the DFCS approved providers
who appear on the approved provider
listmay provide assessmentservices
(listavailable on the web at
http://dfcs.dhr.georgia.gov/fostercare
(DFCS Social Services Policy Manual
ref. 1006)
ASSESSMENT
The standard components ofa
comprehensive assessmentare:
 Medical/Health Check
(developmental/dental)
 Psychological
 Education
INITIATION
The DFCS SSCM will complete and
provide a referral Form #1 for a
comprehensive assessmentwithin
twenty-four (24) hours of the 72-hour
detention hearing to an approved
provider (SS Policy 1006/CCFA
Standards).
DFCS SSCM will inform the familyof
the CCFA and the FTM at the 72-hour
hearing.
DFCS will schedule the FamilyTeam
Meeting and the Multi-Disciplinary
Team (MDT) meeting.
The Family Team Meeting will be held
within nine days of the child’s
placementin foster care.
The MDT meeting mustbe held within
twenty-one (21) days of the referral
date.
The SSCM will provide the appropriate
release ofinformation forms and a copy
of the shelter order with form #1.
The SSCM will send a standard letter of
intent, twenty-four hours following the
referral date to the parent, relative
and/or placementresource outlining the
family assessmentprocess and
introducing the particular provider
completing the assessment.
The SSCM will provide all necessary
attachments and documents within 24
hours of the provider’s acceptance of
the referral. (SS Policy Manual 1006)
ASSESSMENT
The SSCM will make available for
review by the provider, the parent and
the child's case records within two-days
of the providers acceptance of the
referral. (Social Services Policy Manual
ref. 1006/CCFA Standards)
INITIATION
CCFA Provider will notify the SSCM
by fax or email of the receiptof the
referral and acceptance or decline of
referral within 24 hours of receiving
the referral. (Social Services Policy
Manual ref. 1006/CCFA Standards).
Provider will make face-to-face
contact with the familyreferred for
services within two business days of
the referral date. (Social Services
Policy Manual ref. 1006/CCFA
Standards)
Provider will advise the County DFCS
Office within five days of the date of
the referral if a determination is made
that the provider is unable to assess
a particular familyor the
parent/caregiver is unwilling to
cooperate.(Social Services Policy
Manual ref. 1006/CCFA Standards)
ASSESSMENT
CCFA Provider mustcontactthe
SSCM and/or the supervisor within
two days of accepting the referral to
arrange a date and time to review the
case record. Provider may take
notes of needed information to
complete the assessment.

POLICY AND
PROCEDURES
CASE MANAGER'S
RESPONSIBILITIES
PROVIDER'S
RESPONSIBILITIES
 Family Assessment
See policy manual - ref. 1006
The SSCM will enroll the child in school
(if appropriate),visit school and/or day
care center according to policy, apply
for Medicaid for each child, and apply
for a social securitycard and a birth
certificate for each child. The SSCM
should begin to prepare a Life Book for
each child. (DFCS Social Services
Policy Manual 1006 and 1011)
Case Manager will complete Form 527
the within the first 5 days of each child
entering care and complete a Form 529
within 5 days of each move. (DFCS
Social Services Policy Manual 1003)
CCFA Provider is responsible for
scheduling all appointments and
arranging transportation.(Social
Services Policy Manual ref.
1006/CCFA Standards) Provider will
schedule all appointments within two
days of the acceptance of the referral.
CCFA Provider will collectrelevant
educational records from the child’s
school.
The mostrecentrecords must
include:grades,discipline reports,
attendance records and
achievements. Provider will have the
educational reportcompleted bythe
appropriate person atthe child's
current school. Provider will review
and interpret educational reportand
summarize in CCFA report. (Social
1006/CCFA Standards).
Provider will arrange and transport
the child to a Health Check Screen
with an approved Health Check
provider within 10 days of the child’s
placementin foster care. Providers
will collectall medical records ifthe
child is medicallyfragile or has
experienced severe physical abuse.
Provider will include the health check
information in the family assessment
report. (Social Services Policy
Provider will schedule and arrange
transportation to an appointmentfor a
psychological evaluation before the
scheduled MDTmeeting. The
provider is responsible for obtaining
background information and
developing the referral question with
the SSCM. Provider will incorporate
recommendations from the
psychological reportinto the Family
Assessmentwritten report.(Social
1006/CCFA Standards)
Provider will complete the family
assessmentas outlined in the CCFA
Standards,making sure to observe
the parent/ child interaction and
interviewing relatives and friends of
the family. (Social Services Policy

POLICY AND
PROCEDURES
CASE MANAGER'S
RESPONSIBILITIES
PROVIDER'S
RESPONSIBILITIES
MDT
Following completion ofthe
components ofthe assessment,a
MultidisciplinaryTeam (MDT) staffing
is required as a part of the
assessmentprocess. (DFCS Social
Services Policy Manual ref. 1006)
MDT
The SSCM and/or a DFCS supervisor
mustattend and participate in the MDT
(Social Services Policy Manual ref.
The SSCM will send written notice
within five (5) days of the MDT meeting
to the parent. The SSCM will inform
the parentof the intentto develop the
initial case plan goals atthe MDT
meeting.
The SSCM will complete the Initial Case
Plan with the parentat the Family Team
meeting and/or MDT meeting. The
Case Manager will provide a copy of the
case plan to the parent; send a copy to
the court system for consideration to
become an order of the court. (DFCS
Social Services Policy Manual 1007)
The designated countystaff will review
and approve the provider invoice within
5 days of receiptbefore submitting itto
the appropriate accounting department.
The SSCM mustupdate the case plan
with any medical,dental,educational
and any therapy services every six
months according to policy. (DFCS
Social Services Policy Manual 1007
&1011)
Manual ref. 1006/CCFA Standards).
The provider will complete all areas in
which information is available on the
Form 419. (Social Services Policy
The provider will complete a
computer generated Genogram on
the family. The Genogram should
reflect the make up of the paternal
and maternal family.
MDT
Provider will facilitate and coordinate
the MDT staffing. (Social Services
Policy Manual ref. 1006/CCFA
Standards)
Provider has 30 days from the date of
the receiptof a referral to complete
the assessment,including gathering
all information and producing a final
written report. (Social Services Policy
Provider will submitthe final written
report and an assessmentinvoice to
the designated countystaff member
within 30 days from the date of
receiptof the referral or requesta
waiver (for up to an additional 15
days). The waiver mustbe requested
within 15 days of the referral date

SECTION II
INITIATING AN ASSESSMENT
A. INTRODUCTION
The permanency planning process begins when the child enters foster care and
continues until goals and objectives of the family case plan are met and services are
terminated. The CCFA reporting standards are based on a time line that is triggered
when a child requires out of home placement and is placed into DFCS custody. The
time line standards were developed to ensure that assessments and reports are
completed in accordance with the key principles of the Adoption and Safe Families Act
(ASFA). ASFA established the national goals for children in the child welfare system as
safety, permanency and well-being.
The most realistic and viable permanency plan, as well as the most appropriate services
to meet the needs of the child and family, are proposed in the Department’s initial case
plan for reunification when safety can be assured. The family assessment is the
foundation of the case plan. It is essential that the CCFA be completed within thirty
days of the child entering foster care to assist in the initial planning for the family.
The Comprehensive Child and Family Assessment (CCFA) is the property of the
Department of Family and Children Services (DFCS) and, therefore, can only be
released to third parties by DFCS staff.
Only State Approved Providers are allowed to complete a Child and Family
Comprehensive Assessment or provide Wrap-Around Services. The approved
CCFA/Wrap-Around Providers are listed on the web at:
http://dfcs.dhr.gerogia.gov/fostercare.
(1) Referrals for an Assessment
The DFCS Social Services Case Manager will complete and provide, to the vendor, a
Referral for Assessment Form # 1 for a comprehensive assessment within 24 hours
of the conclusion of the 72-hour detention hearing, if the child remains in DFCS custody.
The DFCS SSCM should include any significant or unusual information about the child
or family on the referral form (e.g. child is hearing impaired). The referral form must
include the referral date along with the scheduled date of the Family Team Meeting and
the Multi-Disciplinary Team (MDT) meeting. The DFCS SSCM or Supervisor will
facilitate the FTM, which must be held within nine (9) days of the child’s placement in
foster care. The MDT meeting will be facilitated and coordinated by the CCFA provider
and will be held within twenty-one (21) days of the referral date for the assessment. The
SSCM will include the names of family members, friends, etc. who should be invited to
the Family Team Meeting and/or the MDT meeting as part of Form # 1. The SSCM
should notify the parent and family members of the CCFA and the FTM at the 72-hour

hearing. The DFCS SSCM will provide the name of the local or district public health
representative on the form and will provide appropriate release of information forms and
a copy of the shelter order along with form #1
(2) Provider Acceptance
The provider will notify (by fax or e-mail) the DFCS agency of the receipt and
acceptance or decline of the referral within 24 hours of receiving the referral using Form
1- Comprehensive Child and Family Assessment Provider Referral.
(3) Contact with the Family
Within twenty-four hours (24 hours) of the provider’s acceptance of the referral, the
Social Services Case Manager will send a standard letter of intent to the family and the
placement resource outlining the family assessment process and introducing the
particular vendor completing the assessment. A copy of the letter must also be
provided to the vendor within 24 hours of the acceptance of the referral via email, or fax.
The provider will make face-to-face contact with each family member referred for
services within two business days of receipt of the referral. In making contact, the
provider must present to the family picture identification and a copy of the referral letter.
The DFCS Case manager will assist the provider in gaining access to family
members enrolled in active treatment programs (i.e. alcohol or substance abuse
and/or incarcerated).
(4) Pre-evaluation
The actions identified on the Pre-Evaluation checklist are completed by the SSCM and
provided to the vendor within twenty-four hours of the provider’s acceptance of the
referral. The SSCM is responsible for providing all information and actions listed on the
Pre-Evaluation Checklist. (Sample letters on cc – CPS Case record, Placement,
Assigned Provider)
(5) Copies of Case Record Information
Social Service Case managers are responsible for providing appropriate copies of all
reports and/or other information from any DFCS case files as indicated on the Pre-
evaluation Checklist. SSCM’s are responsible for providing this information to the
provider within 24 hours of the provider’s acceptance of the referral. This
information will aid the provider in completing the assessment.
The Provider must contact the Social Services Case Manager and/or the Supervisor
within two days of accepting the referral to schedule time to review the case record.
Case records must remain in the County DFCS office at all times. Certain portions of
case records remain confidential (e.g. the "reporter" information). The SSCM can
provide relevant copies of any report as long as any specific confidential information is
first concealed.
The Social Services Case Manager is responsible for copying any relevant
information/reports from existing case records and documenting on a Form 452 about

all released information as follows:
 Information released,
 Date, and
 To whom the information was provided, and if applicable, the reason why
information not appearing on the Pre-Evaluation Checklist was released.
If it is determined that the provider needs information that is not on the Pre-Evaluation
Checklist, the SSCM may only release this information with the approval of the
supervisor (or if outlined by the county, the county director and/or designee may be
required to provide approval).
Note: Once the review is complete, the Reporter’s information must be filed back in the
case record.
(6) Unable to Assess a Family.
The provider will advise the County DFCS Office if they make a determination that they
are unable or unwilling to assess a particular family within five days of the date of
receipt of the referral. The provider will provide written communication stating the
reasons for this decision.
(7) Scheduling and Transportation
The provider is responsible for scheduling all appointments and arranging transportation
to and from appointments. Within two business days of accepting the referral, the
CCFA provider schedules all of the necessary appointments.
(8) Court Appearance
Appearance and/or testimony in court proceedings by the CCFA provider is part of the
assessment process (see page 16). If sixty days beyond the referral date, the CCFA
provider is required to appear/testify in court, the county may reimburse at the rate of
$50.00/hour (professional) and $25.00/hour (paraprofessional). A subpoena is required
and should be submitted with the invoice.
(9) Termination/ Cancellation of a Comprehensive Child and Family
Comprehensive Assessment (CCFA)
The County Department has the right to terminate and/or cancel a CCFA
Comprehensive Child and Family Assessment if a child returns home at the
Adjudicatory (10 Day) Hearing.
The County Department will reimburse the contractor for each completed section of the
CCFA. The invoice with completed work must be submitted within ten (10) calendar
days of cancellation date. The amount reimbursed will be based on the documented
completed work.
If the county views that the CCFA will assist the DFCS agency in continuing to work with
the family, the County Director and/or designee may choose to have the assessment
completed even though the child was returned home.

CCFA REFERRAL FORM 1
Indicate Application Type: Medical Assessment/Health Check (0-18) MPI (0-18)
Educational Assessment (5-18); (4 & under, if in early intervention) Psychological (4-18)
Family Assessment (0-18) Relative Home Evaluation (0-18) Adolescent Assessment (14-
18)
Maltreatment (Check all that apply): Physical Neglect Sexual Emotional Other
County Name County Code
Child's Name Child's Case #:
Parent's Name Parent's Phone#:
Parent's Address
DFCS CPS Case Manager: Phone/Fax/Pager:
DFCS Foster Care Case Manager: Phone/Fax/Pager:
DFCS Supervisor Name: Phone/Fax/Pager:
CASA Name: Phone/Fax/Pager:
HOUSEHOLD MEMBERS
Name DOB Relationship In
Home
Out of
Home
Phone #
CHILDREN REMOVED FROM HOME
Name Gender Ethnicity DOB SSN#
Child #1 Male Female
Relationship To Case Child's Current Placement Phone # Medicaid #
Child #1
Child #2
Child #3

Child #4
Child# 5
Child #6
Child # 7
Child’s Name: __________________________________Date of Removal:
________________________
Current School:
________________________________________________________________________
School Address & Telephone #:
___________________________________________________________
____________________________________________________________________________________
_
Name of Child(s) Physician: ___________________________ Physician Phone# _________________
Physician
Address______________________________________________________________________
Name of Child(s) Dentist: _____________________________ Dentist Phone#
____________________
Dentist
Address________________________________________________________________________
Reason Child Was Removed:
____________________________________________________________________________________
__
____________________________________________________________________________________
__
____________________________________________________________________________________
__
____________________________________________________________________________________
__
Comments/Additional Information:
____________________________________________________________________________________

__
____________________________________________________________________________________
__
____________________________________________________________________________________
__
____________________________________________________________________________________
__
____________________________________________________________________________________
__
Child’s Current Placement: DFCS Foster Home Group / Institutional Placement
Private Agency Foster Home __________________Contact/ Number:
__________/________________
Placement Address / Phone Number:
____________________________________________________________________________________
__

Multidisciplinary Team Meeting and Family Team Meeting Form 1
Case Name: _____________________________________________________________ Case
# ________________
Individuals listed below should be invited to attend the MDT and/or FTM as indicated.
Please note that participation is not limited to the individuals below. Any persons
identified throughout the course of the CCFA who are appropriate to attend either or
both meetings should also be invited.
Name Relationship
To Parent
Address Phone # Type
MDT FTM
Meeting Date / Time/ Location
Family Team Meeting
Multidisciplinary Team Meeting
Comments:
_____________________________________________________________________________
_____________________________________________________________________________________

__
_____________________________________________________________________________________
__
_____________________________________________________________________________________
__
_____________________________________________________________________________________
__

PRE-EVALUATION CHECKLIST FORM 1
Child's Name: ______________________________ Case #:
_________________
Pre-evaluation Checklist. The case manager must provide pre-evaluation information within 24
hours of the provider’s acceptance of the referral. The case manager must complete the actions
on this checklist and provide to the vendor copies of any relevant reports/information from the
case records. See Section II.A. (5).
Referral Questions
Generate referral questions. An individual or a team may generate referral questions. Ideas for a referral
question maybe gathered from case managers,foster parents,biological familymembers,fictive kin, facility
representatives,physician,teachers,etc. Referral questions maybe general or specific.(General:We are
seeking a child’s cognitive abilitylevel, currentachievementlevel and an emotional profile.) (Specifi c:Is this
child mentallychallenged? Does this child have dyslexia? Does this child have ADHD?)
Background Information
Provide background information. The case manager,foster parentand/or facility representative mustbe
available to the psychologistto provide background information and to complete developmental and
behavioral questionnaires.If an adult who has limited knowledge ofthe child provides transportation,then it
is the responsibilityof the case manager and/or facility representative to set up an in-person or telephone
appointment. The purpose ofthis appointmentis to provide the information within one week of the
evaluation so the report can be completed in a timelymanner.
Previous Reports
Provide copies ofprevious reports. Copies ofall prior psychological evaluations,psycho-educational reports
and other relevant reports should be provided to the psychologistwhen the child is transported to the
evaluation.It is the responsibilityof the case manager to determine ifthe child has been receiving special
education services or has been considered for special education services.
Medications
Provide information on medications. Inform the psychologistifthe child is on medication atthe time of the
evaluation.A listof all medications should be provided to the evaluator at the time of the evaluation.
Other Factors or Disabilities
Listany other factors that may assistthe psychologistin conducting the psychological evaluation. Some
examples the case manager is responsible for considering during the pre-evaluation process include:
 Cultural or Language Issues
It is expected that the evaluator will be sensitive to cultural and language issues during the evaluation and
when writing his/her report.
 Specialized Assessments
Children in placementoften exhibit a wide range of problem behaviors ata rate higher than the general
clinical population.These behaviors may require further specialized assessments. These assessments are
not included in the psychological or the CCFA. If a specialized assessmentis required, it is in addition to
the psychological. The county department’s approval is required,for billing purposes,before initiation ofthe
specialized assessment.
 Children Left Unaccompanied
Children/youth shall not be left in the office for an evaluation. The CCFA provider mustcontactthe
case manager,facilityrepresentative or foster-parentimmediately ifthe evaluation is discontinued or an
emergencyarises. Many of these children have been traumatized by the changes in their lives and may not
be able to focus.If it is determined thata valid assessment cannotbe completed, it is the psychologist's

responsibility to discontinue the session.
_________________________________ ___________________________
Signature of Case Manager Completing Checklist Date Completed
CCFA PROVIDER ACCEPTANCE/DECLINE FORM FORM 1
_____________________County DFCS Date of Referral: __________________________
Case Name: ___________________________________
DFCS Contact Name:_____________________________________________
Phone Number:____________________
Email Address: ________________________________________
Fax Number: _____________________
Supervisor Name: ______________________________________
Phone Number: ___________________
Email Address: ________________________________________
Fax Number: _____________________
CCFA Provider:____________________________________________________
Please review the information provided on Form 1 and indicate
your acceptance or non-acceptance of the referral by fax or e-
mail within 24 hours of receipt to the DFCS contact indicated
above.
Date of Receipt: ______________________
Date of Response: _____________________
Referral Accepted
Referral Assigned To: (Name /License)
_____________________________________ ______________________
Name License
Phone: ________________ Fax: _________________

Email: ___________________________
Referral Not Accepted(Please indicate reason)
________________________________________________________________
__
______________________________ _______________________ ______________
CCFA Provider Contact Name Signature Title

E. Comprehensive Child and Family Assessment (CCFA) Payment Schedule
The county department will decide which components and reports are needed for the
assessment process and will only pay for the completed components. The
Comprehensive Child and Family Assessments (CCFA) will include one or more of the
following components and reports:
 Psychological (ages 4 – 18)
 Family Assessment (age 0 – 18)
 Educational Assessment (age 5 – 18) If child is in early intervention 4 &
under
 Health Check (age 0 - 18), includes a dental screen for (age 3 - 18) and
developmental screen for (age 0 - 3)
 MDT Report (age 0 – 18)
 Family Team Meeting (age 0 – 18)
 Match Profile Instrument (age 0 - 18)
The County Department agrees to pay the contractor per referral according to the
progress payment schedule. Payment is contingent upon the completion of tasks as
identified in the Progress Payment Schedule and compliance with the standards.
1. Comprehensive Child and Family Assessment includes the compilation of
the Comprehensive Child and Family Assessment as well as appearing and
testifying in Court if required and compliance with the (CCFA) standards. The
Comprehensive Assessment must include all components as requested by
the county, facilitation of the MDT meeting, participation in the FTM,
completion of a Genogram, and DFCS Form 419. In addition, information on
relative’s as potential placement resources must be included. Appearance
and testimony in court is within the first sixty days of the assessment and is
compensated as follows:
Amount: $600 one child
$300.00 each additional child
2. Assessment Components includes compilation of any individual component
of the assessment will be reimbursed at the following rates:
Family Assessment $600.00/one child
$300.00/additional child
Educational Component $150.00/child
Medical Component (includes Dental $150.00/child
and Developmental screen) $150.00/child
Psychological $300.00/child
Match Profile Instrument (MPI) $ 75.00/child

SECTION III
PSYCHOLOGICAL ASSESSMENT STANDARDS & REPORTS
AGES 4 TO 18
A. INTRODUCTION
To obtain information on the child’s mental health, children (ages 4-18) require a
psychological evaluation when they first enter care using the Comprehensive Child and
Family Assessment (CCFA) standards. Infants and toddlers (age 0-3) will have a
developmental screen as part of the Health Check Screen. See Section VII.
A psychologist participating in the Medicaid program, Peach Care, Georgia Better
Healthcare or the child's insurance plan should complete a Psychological evaluation.
A psychological evaluation is a written report of the information collected during the
evaluation. This report should include, but is not limited to, the psychological status of
the child or adolescent at the time they enter foster care. If the psychological
evaluation yields any psychological or developmental delays or concerns, the
psychological summary and report must provide detailed recommendations and
actions to be taken. The case manager then coordinates services to keep or get the
child or adolescent on target with their age appropriate development.
Every child or adolescent (ages 4-18) must have a psychological evaluation.
NOTE: Do not begin the Psychological Evaluation until the hearing and vision
screening results are available.
(1) Pre-evaluation for a Psychological Evaluation
Before a psychological evaluation is conducted, the case manager or CCFA provider, if
service is purchased, is shall take the following actions:
 Generate a referral question before the request for a psychological evaluation is
sent to the psychologist. (See Pre-Evaluation Checklist) An individual or a team
may generate the referral question. Ideas for a referral question may be
gathered from case managers, foster parents, biological family members, facility
representatives, physician, teachers, etc. Referral questions may be general or
specific. (General: We are seeking a child’s cognitive ability level, current
achievement level and an emotional profile.) (Specific: Is this child retarded?
Does this child have dyslexia? Does this child have ADHD?)
 The provider must have a hearing and vision screening completed prior to
beginning the evaluation. Do not begin the evaluation until the hearing and
vision screening results are available for your records.

 Provide background information. The case manager, foster parent and/or facility
representative must be available to the psychologist to provide background
information and to complete developmental and behavioral questionnaires. If an
adult who has limited knowledge of the child provides transportation, then it is the
responsibility of the case manager and/or placement provider to set up an in-
person or telephone appointment. The purpose of this appointment is to provide
the information within 72-hours of the evaluation so the report can be completed
in a timely manner.
 Provide copies of previous reports. Copies of all prior psychological evaluations,
psycho-educational reports and other relevant reports should be provided to the
psychologist when the child is transported to the evaluation. It is the responsibility
of the case manager to determine if the child has been receiving special
education services or has been considered for special education services.
 Provide information on medications. Inform the psychologist if the child is on
medication at the time of the evaluation. A list of all medications should be
provided to the evaluator at the time of the evaluation.
Other factors the case manager is responsible for considering during the pre-evaluation
process include:
 Children/youth shall not be left in the office for an evaluation. The CCFA provider
must contact the case manager, facility representative or foster-parent
immediately if the evaluation is discontinued or an emergency arises. Many of
these children have been traumatized by the changes in their lives and may not
be able to focus. If it is determined that a valid assessment cannot be completed,
it is the psychologist's responsibility to discontinue the session.
 It is expected that the evaluator will be sensitive to cultural and language issues
during the evaluation and when writing his/her report.
 Children in placement often exhibit a wide range of problem behaviors at a rate
higher than the general clinical population. These behaviors may require further
specialized assessments.
(2) Psychological Evaluation
A psychological evaluation should include, but is not limited to, a review of the following
domains or areas: (See below for examples of further assessment domains)
 Identifying data
 Reason for referral
 Background
 Past evaluations and treatment
 Behavior observations/mental status

 Evaluation Results
 DSM IV-Multi-Axial Diagnosis
 Summary and Recommendations
 Must address the referral question and presenting problems
 Validity Statement (e.g. This evaluation appears to be a valid reflection of this
child's level of functioning.)
 Placement Recommendations (if appropriate)
 Treatment Recommendations
 Referrals for Additional Assessment (if necessary)
 Signature of Licensed Psychologist, Date
Children or adolescents may require additional specialized assessments. Examples of
specialized assessments are:
 Dissociative Disorders  Fire setting
 Learning Disability  Neuropsychological
 Occupational Therapy Evaluation  Psychiatric Evaluation
 Sexual Perpetrator  Specialized Medical
 Speech and Language Evaluation
 Substance abuse
 Trauma Assessment (sexual, physical)
(3) Adult Psychological Evaluations and Specialized Assessments
An Assessment by means of Psychological, Psychiatric, Speech Therapy Services
(formerly known as PPST) and specialized assessments may be utilized when Medicaid
is not available. The following are eligible to receive assessment and treatment
services:
 Children in foster care,
 Birth parents of children in care when the permanency plan is reunification or
when another permanency plan may need to be selected,
 Relative care givers of children in care when the permanency plan is placement
with a “fit and willing relative” or when another permanency plan may need to be
selected, and
 Foster Parents serving special needs children who require consultation about a
specific child in the home.
Providers must be licensed for the service performed; i.e., psychiatric and psychological
evaluations and therapy must be conducted by a psychiatrist (M.D.) or by a licensed
clinical psychologist (Ph.D. or Psy.D.). These assessments are charged at the
Medicaid billable amount (Fiscal Services – Section 1016.5). Prior approval from the
county department is required before an adult or specialized assessment is initiated.
If an adult or specialized assessment is recommended, and there is no identified
funding source to cover the cost of the assessment, the county department may
authorize payment using assessment funds. The county department will provide the
CCFA provider with Form 535, Authorization and Claim for Psychological, Psychiatric or

Speech Therapy Services, completed and signed by the County Director/designee. The
county department must provide instructions to the CCFA provider for submitting the
claim to the county department for services rendered.
(4) Who Can Complete the Psychological Evaluation
Psychological evaluations are to be completed and signed by a licensed psychologist
and/or a psychiatrist. A non-licensed individual from an agency (Bachelor’s level
education or paraprofessional) may accompany the child to the appointment and
provide all background information including the referral question to the Psychologist.
The provider will also ensure that a copy of the Psychological evaluation is submitted
with the CCFA report.
B. AGES 4 TO 18 ASSESSMENT REPORT
The title and format of the report is as described below and must include the following
nine (9) sections. These are minimum standards. Psychologists may expand these
standards to reach assessment goals.
Report Title: Psychological Evaluation Report
1. Identifying Data
 Name
 Date of Birth
 Child's Social Security Number (if applicable)
 Date of Referral
 Date of Evaluation
 Names of the following:
 Parent/Guardian
 Foster parent
 Referring person and agency
2. Reason for Referral
3. Background Information
 History of child/youth
 Present placement
4. Summary of Past Evaluations and Treatment
5. Behavior Observations/Mental Status
6. Evaluation Results
 Include name of test and scores (standard scores, percentiles, grade equivalent
scores)

 Summarize results and findings of each test
It is the responsibility of the Psychologist to review previous psychological reports to determine if
an IQ test needs to be repeated within the three-year window. If an IQ test does not need to be
repeated, it is expected that the psychologist will use the extra time for extended achievement
screening or personality measures.
The following sections are completed for each child receiving comprehensive
assessment services:
A. Intellectual Assessment
 IQ score from the WISC-III, Stanford-Binet, WAIS-R, DAS (Differential Abilities
Scale), Bayley Scales of Infant Development, WPPSI-R
 An IQ test does not need to be repeated:
 If a child has had an IQ score completed with the WISC-III or Stanford-
Binet within three calendar years,
 If the child was at least 7 (seven) years of age at the time of the earlier IQ
test, and
 If a child will not be referred for Level of Care services.
 An IQ test must be repeated:
 If a child was under 7 (seven) years of age at the time of the earlier IQ
test,
 If the child has had a head injury or evidence of serious mental illness has
emerged since the initial evaluation,
 If the child was not on medication (such as Ritalin) during the earlier
evaluation, and
 If a child will be referred for Level of Care services, an IQ test must be
current and completed within one calendar year.
NOTE: Abbreviated scales (Kaufman Brief Intelligence Test -KBIT or Wechsler
Abbreviated Scale of Intelligence -WASI) are acceptable only if the child's scores fall at
the Low Average or above. Children with Borderline or Intellectually Disabled scores on
an abbreviated instrument will need an IQ score from a Full battery. Children with
evidence of Learning Disabilities will need an IQ score from a Full battery.
B. Adaptive Behavior Scales
 If IQ falls within or below the Mildly Mentally Retarded Range an Adaptive
Behavior Scale must be administered (i.e. Vineland, AAMD).
C. Academic Screening and Assessment.
 WRAT - 3 (Wide Range Achievement Test) may be used for screening. WJ II -
The (Woodcock-Johnson II) or WIAT - (Wechsler Individual Achievement Test) is
preferred for assessment.

 Assessment will need to target problems highlighted by the screening or referral
question. Further referrals for additional evaluation may be required.
D. Personality Measures
 Choice of measures based on age, referral question, IQ, etc.
 Objective (e.g. MMPI-A, RCDS, RADS)
 Projective (e.g. TAT, RAT-Roberts Apperception Test, Rorschach)
E. Standardized Behavioral Check List
 For example, Achenbach, CAFAS, BASC
 Report significant Problem Areas.
7. DSM IV - Multi-Axial Diagnosis
 Include all 5 axes and numerical codes.
8. Summary and Recommendations
 Summary and recommendations must address the referral question, presenting
problems, and the reason the child came into care.
 Supplemental recommendations may be listed. These recommendations should
address the underlying reasons, which impact the child and family functioning.
 A validity statement should be included (i.e. This evaluation appears to be a valid
reflection of this child’s current level of functioning).
 Recommendations for placement (if appropriate)
 Recommendations for Treatment
 Referrals for additional assessment (if necessary)
9. Name, Signature of Psychologist and Date Completed
 License Number
 Only Licensed Psychologists are eligible to complete and sign psychological
evaluations. Psychometricians may be used to administer and score tests. The
psychologist is responsible for diagnoses, summaries and treatment
recommendations.
NOTE: Standards developed by Wendy Hanevold, Ph.D., Licensed Psychologist #1574
(Georgia) 404-583-7333

SECTION IV
ASSESSMENT STANDARDS & REPORTS FOR
ADOLESCENTS & YOUNG ADULTS
AGES 14 TO 20.5
A. INTRODUCTION
The adolescent component of the Comprehensive Child and Family Assessment
(CCFA) provides supplemental information to DFCS’ comprehensive assessment
program. The adolescent component is administered to youth, ages 14-18, if at a
Judicial or Citizens Panel Review the plan for permanency changes to emancipation for
the youth and if the assessment is deemed necessary or appropriate as part of the
review plan. The SSCM will coordinate the assessment with the Independent Living
Coordinator (ILC) and ensure a copy of the assessment is forwarded to the ILC when
completed. The adolescent component is designed to generate information critical to
successfully guiding young people in their journey from foster care to achieving self-
sufficiency. The observations and recommendations derived from the assessment are
presented at a Multi-Disciplinary Team (MDT) staffing. The MDT explores service and
treatment options for an adolescent and makes suggestions/recommendations based
on identified strengths and challenges. DFCS staff, judges, youth, Independent Living
Coordinators (ILCs) and others are to consider this information key in developing a
Written Transitional Living Plan (WTLP) and identifying services to assure safety,
permanency and youth well being. The assessment is strength-based and solution-
oriented and is completed in partnership with teens who assist in identifying their own
areas of strength and challenges as they move toward transition.
The adolescent component of the assessment also serves as a determinant for
participation in DFCS’ Transitional Living Program (TLP). The TLP is a supervised,
scattered site apartment program for youth ages 18-21 who are moving from the foster
care system back into communities. Youth appropriate for the TLP Adolescent
Assessment are generally those who:
(1) are between the ages of 17.5 and 20.5,
(2) are currently in foster care with a signed Form 7 (Consent to Remain in Foster
Care),
(3) were formerly in foster care; i.e. youth in Aftercare status, who remained in foster
care until age 18,
(4) have completed high school, and
(5) have assessment approval from the local ILC.
The following areas and domains are evaluated and included as an integral part of the
assessment: (See Section IV, C for a list of required tools used in the Adolescent
Component.)

1. Independent Living Skills
 Daily Living Tasks
 Self Care
 Housing and Community Resources
 Social Development
 Money Management
2. Family of Origin Strength and Issues
3. Interpersonal Relationships and Social Support Networks
4. Future Perspective
5. Pre-Vocational and Vocational Goals
6. Alcohol and Drug Use
7. Coping Skills and Self Esteem
8. Sensitive Issues
9. Interviews with Youth, Caregivers, Case Managers and Teachers
10. Functioning
(1) Interviews
The assessment is youth centered. Collateral interviews should be completed with
parents, case managers and/or teachers. Collateral material may also be available in
the Family Assessment and Psychological Evaluation.
(2) Report
The report generated from this assessment is to be used to help develop a Written
Transitional Living Plan (WTLP). The WTLP helps to direct the work of the ILC, Life
Coach, Social Services Case Manager and others who serve as a support to the
adolescent. The youth receives a summary of the report and a copy of the WTLP.
(3) Who Can Complete the Adolescent Component
The Adolescent Assessment is to be completed by an individual with a minimum of a
Master’s level of education in Social Work, Counseling, or Psychology with an LCSW,
LMFT or LPC granted by the State of Georgia’s Composite Board of Counselors, Social
Workers, and Marriage and Family Therapists, as well as be in good standing with that
authority. Individuals with a Master’s degree who are under the supervision of an
LCSW, LPC or LMFT may also conduct the Transitional Youth Assessment. In which
case, the Assessment requires two signatures: the licensed supervisor’s and the
Master’s level assessor.
B. ADOLESCENT ASSESSMENT REPORT
The format of the Adolescent Assessment must include the following six sections. The
licensed Master’s level individual must sign the adolescent assessment report.

Report Title: Adolescent Assessment Report
1. Data Section
2. Background and Summary of the Adolescent Comprehensive Child and Family
Assessment
 Reason for Referral and Background Information (e.g. for youth transitioning out
of foster care, for a significant, extenuating circumstance concerning the child
and/or family, etc.)
 Individual Assessment
 Summarize Assessment Conclusions
 Include Diagnostic Impression:
 Axis I
 Axis II:
 Axis III:
 Axis IV:
 Axis V: Global Assessment of Functioning (Current)
 Family Assessment Recommendations and Conclusions. (Include agency name
and date completed)
3. List Instruments Used
All instruments and the name of the person completing each must be used for youth
ages 14 to 20.5. See Appendix C. for a sample Adolescent Profile.
 Draw Your Strength
 Genogram
 Ecomap
 Draw Your Future
 Road of Life
 Rosenberg Self-Concept Scale
 Alcohol and Drug Questionnaire
 Sensitive Issues Inventory
 ACLSA-Level III
 Interview
4. Results of Assessment
A sample adolescent profile template can be found in Appendix C.
5. Summary and Recommendations
6. Name, Signature and Date Completed
Reminders

1. Remember to have the following items included in the appendix of the
assessment report for youth under consideration for TLP participation.
 Draw Your Strength.
 Genogram
 Ecomap
 Draw Your Future
 Road of Life
 ACLSA-Level III: Response Summary
2. The provider should provide the youth a copy of the adolescent component of the
assessment after the MDT is completed.
C. ADOLESCENT ASSESSMENT REQUIRED TOOLS
1. Independent Living Skills (Ages 16-20.5)
 Ansell-Casey Life Skills Assessment (ACLSA) This scale is available for free at
www.caseylifeskills.org
 Daily Living Tasks  Self-care
 Housing and
community
resources
 Social
Development
 Money
Management
 Work & Study
Habits
2. Family of Origin (all youth)
 Genogram. To help youth explore their roots and history.
3. Interpersonal Relationships (all youth)
 Ecomaps (Focus on youth’s friendship and social support network)
4. Draw Your Future Perspective (ages 16 - 20.5)
 Have youth write a passage about their goals and dreams.
 Have youth draw their future goals (e.g. crystal ball drawing - present a line
drawing of a crystal ball and ask youth to draw their future)
5. Alcohol and Drug Questionnaire (all youth)
 This is a two-part questionnaire that asks youth about their current and past
substance abuse.
 This questionnaire is not scored. It is a qualitative instrument. The evaluating
team will need to use their professional judgment to determine if a referral for a

drug screen and/or substance abuse evaluation is recommended. A copy can be
obtained at http://dfcs.dhr.georgia.gov/fostercare.
6. Coping Skills and Self-Esteem (ages 16 - 20.5)
 The designated Self-Esteem – Rosenberg Self-Concept Scale
 Draw Your Strength
7. Life Experience-Inventories and Questionnaires (All Youth)
 Sensitive Issues Inventory-Adolescent. A copy can be obtained at
http://dfcs.dhr.georgia.gov/fostercare
8. Interviews (all youth)
 The assessment is youth centered.
 Collateral interviews should be completed with parents, caseworkers and/or
teachers.
 Collateral material may also be available in the Family Assessment and
Psychological Evaluation.
Note: The above is a list of required instruments and questionnaire. You may add
additional tools and assessment results to the Adolescent (Transitional Youth)
Assessment.

SECTION V
ASSESSMENT STANDARDS & REPORTS FOR FAMILIES
A. INTRODUCTION
The goal of the Family Assessment is to provide a comprehensive assessment of the
family. The assessment provides the foundation for effective case planning,
intervention and decision-making. DFCS staff uses the assessment information to
assist judges, CASA, Citizen Panels, families and other providers working with the child
and family in making placement decisions and the identification of services to ensure
the safety, permanency and child and family well-being. Observations and information
from the Family Assessment will be presented at the Multi-Disciplinary Team staffing
(MDT). The MDT will explore options for the family and make
suggestions/recommendations about placement and service interventions/provisions for
the family (e.g. family preservation, family therapy, parent aide, etc). Goals that are
positively stated, measurable, and address the specific behaviors or conditions that
must be corrected for the child to be safely returned, will be incorporated in the initial
case plan for the family.
The Case Manager will be responsible for updating the Family Assessment at a
minimum of every two years per Social Services Policy Manual reference 1006
The family assessment must include (if applicable), but is not limited to, the following
information:
 Reason for Referral
 Household Composition/Key Data (See page 39 for various stages)
 Clinical Observation
 Prior Agency Involvement
 Living Arrangements
 General Financial Status and Employment History
 Health of All Household Members
 Marriage Status
 History of Criminal Activity (parents and children)
 Education Status
 Relationship between Parent and Child
 Relationship between Placement Resource and Child
 Family and Community Resources (i.e. Transportation)
 Family's Strengths and Needs
 Relatives and resources for support, placement, and possible permanency
 Efforts to place siblings together and reasons they were not placed together, if
applicable
 Does the parent or child have Native American Heritage?
 Reason child is placed a substantial distance from their home, if applicable.

 Genogram (as a required attachment)/DHR Form 419
 Summary, Conclusions, and Recommendations
KEY QUESTION: Can the child's parents/caregivers mobilize their internal and
external strengths and resources to successfully meet each of their children's
needs?
Examples of questions to ask during the assessment
 What are the safety and protection issues that must be addressed?
 What are the family's strengths?
 What are the family's limitations and needs?
 What are the factors that need to be reviewed to determine if the child can be safe in
their family?
 Can this family meet the individual child's' needs?
 What are the resources for this family? (Extended Family and Community)
 Does this family have a clear and appropriate hierarchical structure?
 Is this family overly distant (disengaged) or overly close (enmeshed)?
 Are there major substance abuse issues?
 Are there major mental health issues present in this family?
 Is there evidence of a serious personality disorder in one or more caregivers?
 Can the family manage the basic tasks of life, such as providing food and shelter?
 Do the caregivers have the ability to manage their children's behavior in age-
appropriate and safe ways?
 Is there a multigenerational pattern of abuse and neglect?
 What is the parent's level of empathy for each child?
 What has helped this family in the past?
 What is the parent/caregiver's attitude towards available resources?
 How does this family cope with crisis?
 What is the history of sensitive issue? Is this family (trauma, loss) and how have
they coped with past issues?
 How does this family cope with crisis?
 What are the resources for this family?
(1) Dynamic Assessment
Family assessments must be based on a combination of observations, interviews, self-
report measures and social history.
Family self-reporting is insufficient. Family history is insufficient. The family must be
observed in action (enactments). The assessment must be dynamic (it should reveal
the family's energy, style, and behavior). If at all feasible, see families over a period of
time. Having only one observation session may result in a distorted picture.
The focus of the assessment is on the dynamic observations and interactions observed

during the assessment. Standardized self-report instruments may be used to gather
information. Although a social history and a background information section need to be
included, this section is only one of the sections of the assessment or report. Integrate
the history and background sections into the conclusions and recommendations.
Observations need to confirm or not confirm a self-report. Observe the family in action
and do not accept their report of their behaviors as the primary source for assessment.
All parents must be interviewed. This includes absent or incarcerated, putative,
legal, adoptive or any other parent category not listed. The required method is a
face-to-face interview. If a parent is absent or incarcerated, then a telephone or
written interview is appropriate. In any case, a written explanation must be
included in the report explaining why a face-to-face interview was not
accomplished. This statement should document all attempts to secure interviews.
Extended family members must be contacted. If the custodial parents refuse to permit
contact with extended family members, the DFCS case manager determines if contact
should occur despite the custodial parent's protest. When interviewing the extended
relatives, the provider should explore resources for support, placement and possible
permanency. The Provider may also obtain information on other relatives to contact.
The CCFA Provider should contact DFCS immediately, if a relative is identified as
a placement resource for the child. DFCS may request an approved CCFA provider
to complete a home evaluation on a relative(s).
Key: Observe the family in at least one setting. Use a combination of
unstructured and structured observations. A home visit is required to complete
the Family Assessment.
Note: It is the responsibility of the assessment team to provide age-appropriate
materials to engage children and caregivers for the purpose of observation and
assessment.
(2) Stages of Assessment of Key Family Members
The family subsystems should be seen together and in separate units. It is
recommended that the assessment take place in two or three stages.
Stage I: See the parent/caregiver(s) first. During this stage the family assessor can:
 Determine who is in the household.
 Identify family members (not living in the household) relatives who have an impact or
important role for this family (e.g. grandmothers, parents, etc.). Are any of these
individuals’ potential placement resources for the child?
 Identify non-family members who are important to this family (e.g.
boyfriend/girlfriends, pastors, neighbors, etc.).

 Obtain a developmental history of the child (children). This history will provide an
opportunity to obtain the parent's perception of their child, knowledge of
developmental issues and parenting skills.
 Explore individual caregiver issues and obtain an initial mental status for each
caregiver. At this stage, it may be determined that a parent(s) require a
psychological evaluation and/or a substance abuse evaluation.
 This first stage can provide an opportunity for the initial assessment of the couple's
relationship.
Stage II: The child (or each child in a sibling group)
 The child should be seen alone to obtain the Child's Perception of his parents and
his family.
 This stage can be included in the Individual Child Assessment.
Stage III: The family subsystems should be seen together and in separate units.
The family should be seen together unless there is a serious, well-documented basis
preventing the family system to be seen as a unit. For example:
 Child with parent (or caregiver) 1 and 2 (both caregivers together with child)
 Child with parent or caregiver 1
 Child with parent or caregiver 2
 Family unit (household unit-parents/caregivers, siblings, target child (children)
 Extended Family/Community: As many family members/community resources
that can be gathered for the assessment.
 Family Team Meeting ("Family Team Meeting” is a gathering of family
members, friends, community specialists and other interested people who join
together to strengthen a family and provide a protection and care plan for
their children." From The Child Welfare Policy and Practice Group).
(3) Who Can Complete the Family Assessment
The Family Assessment is to be completed by an individual with a minimum of a
LMFT or LPC granted by the State of Georgia’s Composite Board of Counselors, Social
Workers, and Marriage and Family Therapists, as well as be in good standing with that
authority. Individuals with a Master’s degree who are under the supervision of an
LCSW, LPC or LMFT may also conduct the Family Assessment. In which case, the
Assessment requires two signatures: the licensed supervisor’s and the Master’s level
assessor.
B. FAMILY ASSESSMENT REPORT
The title and format of the report is as follows and must include the following nine (9)
sections.
Report Title: Family Assessment Report

1. Key Data
 Dates and locations of assessment (include who was present during the
assessment on each date)
 Name(s) of assessors
 Name of case manager
 List of key family members (family of origin and family of procreation)
 Interviews with all parents and alleged parents including absent and incarcerated
parents
 Contacts with extended family members. If the custodial parents refuse to permit
contact with extended family members, the DFCS case manager determines if
contact should occur despite the custodial parent's protest.
*Document attempts to reach family members - include date of attempt and how contact
was attempted
 Note the Key Family Members who were seen for assessment
 Note key family members who were not seen during assessment
 Note who lives in home (* might signify lives in home)
 Note who lives outside the home
 Example of Family and Community Members:
Name Age Relationship Seen for
Assessment
Sara Jones 23 Mother Yes No
Thomas B.* 31 Boyfriend Yes No
 Interview Outline
 Interviewed (list all those interviewed, i.e. identified Client, biological
mother, biological sister, maternal half-sister, etc.)
 Not Interviewed (list all not interviewed; i.e. Biological Father). (He is
presently serving a prison sentence in North Carolina)
 Provide following interview information for each interview conducted:
Date Location Present Relationship Age
 Telephone Contacts (List information for each contact as follows)
Date Location Conversation
2. Reason for Referral
State the reason the child/family is being referred for assessment.
3. Family Summary/History
Background information on the child’s and family history
4. Clinical Observation
This section includes behavioral observations of key individuals, couples, parent-child
interactions, and family structure. These findings are not based only on the report, but

are also gathered through observations and the use of clinical judgment.
5. Areas to Be Assessed
A. Prior Agency Involvement
 Mental Health, DJJ/Corrections, Public Health,
 Economic Support/Social Services/Childcare/Child Support
 Other
B. Living Arrangements
C. General Financial Status and Employment History
D. Health of All Household Members
E. Marriage Status
F. History of Criminal Activity (parents and children)
G. Education Status
H. Safety and Protection
 Review the investigation and determination information and findings from
the Child Protective Services investigation and the Risk Assessment.
I. Caregiver Child Interactions
 Parent's perception of child
 Listen to how parents describe their child
 Daily Routines (Have family describe a "typical day.")
 Parents awareness of child's needs (physical, emotional, cognitive and
social)
 Emotional bonds to family
J. Child's Perception of Parent
K. Parent's Knowledge of Parenting
L. Limit Setting Skills and Discipline
 Can the parents set limits with their child (children)?
 Are clear boundaries and hierarchies present between parent and
child(ren)?
 Any known problems and/or presenting behaviors of children (e.g.
substance abuse, delinquency, sexual behaviors, academic problems)
M. Couple/Relationship
 Do partners work together as a unit?
 Do partners agree or at least agree to disagree?
 What is the risk for domestic violence (ask each partner without the other
partner present)?
 Separation, divorce and stepfamily issues. How do separated parents
(grandparents) work together as a unit?
N. Family Stressors and Resources
 Living Conditions
 Financial Conditions
 Supports and Resources
 Health
 Housing
 Employment
 Transportation

 Coping skills
O. Caregiver(s) Strengths and Limitations
 Information for this section may best be completed by an individual
assessment of each caregiver/parent. The findings of the individual
assessment may then be used to explore how the following areas
determine this family's needs, ability to protect, interpersonal and intra-
personal resources:
o History of trauma-physical sexual emotional-neglect
o Look for disassociation and Post Traumatic Stress Disorder (PTSD)
in caregivers.
o History of substance abuse
o Current substance abuse
o Physical violence
o Other criminal behavior
o Adult victimization-domestic violence
o Cognitive level
o Mental Illness
o Emotional stability, depression, mood swings, impulsivity, though
disorder, personality disorders
o Management of anger
o Problem solving and coping skills
o Self-esteem
o Physical health-medication
P. Child Strengths and Needs
 The Child Assessment should provide a profile of the child's strengths and
needs.
 Adolescents (ages 14-18) must complete the Alcohol and Drug
Questionnaire. Information from the questionnaire must be included in the
assessment.
Q. Collection of Information for Form 419 (Background Information for State
Agency CHILD)
 Document any areas on the form in which information was not
obtained by stating what attempts were made (how) and the reason
why information was not obtained.
6. Summary/Conclusions and Recommendations
The summary section should provide a dynamic picture of the following family issues:
 Safety and Protection Issues (A review of the Risk Assessment completed in
CPS and the identification of risk factors should be included in the report)
 Strengths
 Limitations and needs
 Resources-within the nuclear family, the extended family, community resources
 Coping skills
 Fit between parent and child

The Focus of the report is on the integration of the dynamic observations and
interactions observed during the assessment, social history, interviews, and results from
standardized measures.
7. Signature, Credentials and Date Completed
The Family Assessment must be completed by an individual with a minimum of a
LMFT or LPC granted by or the State of Georgia Composite Board of Counselors,
Social Workers, and Marriage and Family Therapists, as well as be in good standing
with that authority. Individuals with a Master’s degree who are under the supervision of
an LCSW, LPC or LMFT may also conduct the Family Assessment. In which case, the
Assessment requires two signatures: the licensed supervisor’s and the Master’s level
assessor. However, the licensed supervisor is responsible for the overall assessment
and report.
NOTE: Family assessments do not have to be based on any specific school of family
theory but the assessors must have training and experience in family systems and be
able to assess families based on a systemic theory using systemic techniques. (e.g.
enactments and observations).
9. Required Attachments
 Genogram – must be computer generated.
 Form 419 - Background Information for State Agency Child (All 7 pages and all
sections of the form must be completed and typed (information should be
completed as it can reasonably be obtained) The form may be accessed at
http://dfcs.dhr.georgia.gov/fostercare.
 Alcohol and Drug Questionnaire for adolescents (ages 14-17)

Georgia Departmentof Human Resources
BACKGROUND INFORMATIONFOR STATE AGENCY CHILD FORM
419
Worker/Title: Birth Name of Child:
Telephone #: Date: Date Birth of Child: Time of
Birth:
Sex:
Home County: Boarding County: Race/Ethnic:
Child’s Mother Grandmother Grandfather Father Grandmother Grandfather
DOB
Race/Ethnic
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased
Age & Cause
Special
Characteristics
Child’s Maternal Aunts & Uncles Child’s Paternal Aunts & Uncles
DOB
Sex

ALL RELATIONSHIPS ARE TO THE CHILD
CHILD’S NAME: __________________________
Maternal Paternal
(Add additional pages if necessary)
Form 419 (Rev 2-99)
ALL RELATIONSHIPS ARE TO THE CHILD
SIBLINGS OF CHILD
MATERNAL
Race/Ethnic
National Descent:
Hair Color:
Eye Color:
Complexion:
Weight:
Height:
Occupation:
General Health:
Education:
If Deceased
Age & Cause
Special
Characteristics

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