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CS 0172 - Foster Care Annual Assessment

By Jason King,2014-10-17 11:17
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CS 0172 - Foster Care Annual Assessment

    Foster Care Annual Assessment

    CHILDREN’S SERVICES

    Instructions to Foster Parent

     The information you provide on this form is collected under the authority of the Child, Youth and Family date Enhancement Act. The information will be used to ensure

    the appropriateness of continuing to place a foster child

    in your home and ensure that the needs of a child placed

    in your home are appropriately matched with your

    abilities. We will not release this information for any other

    purpose. If you have any questions about the collection

     Dear , of this information, you may contact your caseworker.

    Please find enclosed the part of your Annual Assessment that you need to complete. Before beginning, read through the questions to familiarize yourself with what is required. You will note that there are 3 different pages of information to be completed. Each page is a 2 part form, one part is on white paper the other part is on pink paper. Please ensure that you keep the cardboard behind the pink copy (part 2) of the page you wish to complete. Currently the cardboard is behind this page. As you move from part to part completing the form please ensure the cardboard is behind the pink copy of each page. If you need any additional space please attach an extra sheet.

     I will be meeting with you on , to go over your Annual Assessment. If this is not a good time please contact me at to arrange a different time.

     I will be contacting you to arrange a time to go over your Annual Assessment.

    Please ensure you have answered the attached assessment as completely as possible before you meet with me. Once you have met with me and all paperwork is completed, I will send you a copy of the Assessment. Sincerely,

    Signature Foster Care Caseworker

    Foster Care Caseworker: Once you have completed the above information tear here ; ;

    and retain these instructions for your reference.

    Instructions to Foster Care Caseworker

    Complete the top portion of this fly sheet. Remove the bottom portion for your reference.

    Send Foster Parent the Foster Home Annual Assessment (top copy and first 3 pages) 1 month prior to meeting

    with them.

    Send Evaluation by Child(ren)’s Caseworker to each caseworker with a child in the home. (If there are fewer than 3

    children in this home, retain unused forms for situation where there are more than 3 children in a home).

    Once you receive the reports back from the Child(ren)’s Caseworker complete your assessment using the same

    form (CS0172). The form is on WORD under CS0172.

    Meet with foster parents to review and discuss assessment. Ensure appropriate people have signed the document.

    Send a copy of your Foster Care Annual Assessment to the Foster Parents.

    Retain the top copy of the Foster Care Annual Assessment (white copy) on the foster care home file.

CS 0172 (2004/11) ___ Worksite File - Foster Home File File Section 3

     ___ Worksite File - Child’s File File Section 1

     Page 1 of 4

    Foster Care Annual Assessment

    CHILDREN’S SERVICES

    The information you provide on this form is collected under the authority of the Child, Youth and Family Enhancement Act and is managed in compliance with the Freedom of Information and Protection of Privacy Act. The information will be used to process your licensing renewal. We will not release this information for any other purpose. If you have any

    questions about the collection of this information, you may contact your caseworker.

l. Applicant’s Information

    Name of Foster Family Type of Foster Home (please check one)

     Authority/Delegated First Nation Agency Agency Date of Last Review Date of Review Date of Initial Approval Address of Foster Family (yyyy/mm/dd) (yyyy/mm/dd) (yyyy/mm/dd)

    Current Classification (please check one)

     Level One Level Two Specialized License Expiry Date # of Children in Home First Aid Expiry Date (yyyy/mm/dd) (yyyy/mm/dd)

Indicate all Foster Care placements and removals during the last year. Include current placements.

    Name Date of Birth Placement Date Removal Date Reason for Removal (yyyy/mm/dd) (yyyy/mm/dd) (yyyy/mm/dd)

Except for family members indicate all other people in your household, their ages, relationship to foster parent(s). Please

    include renters, boarders etc.

    Name Age Relationship to foster parent(s) Role in relation to fostering

Have you or any member of your household been charged or convicted of a criminal offence since Yes No your last annual assessment? X Please provide details.

     If either foster parent is employed outside the home, indicate current employer and occupation, as well as usual hours of

    work.

    Name Current Employer Occupation Usual Hours of Work

ll. Family Dynamics

    Please comment on significant changes in the area of finances, health, education, relationships or family stresses since your last annual assessment.

Describe the extent which you have been involved in working with natural families.

What are the spiritual and cultural practices in your home?

How have you assisted each child to develop his/her spiritual and cultural identity both within and outside your home?

    Please describe how you have worked effectively with a child who has some serious, moderate or mild behavioral difficulties.

How do you encourage appropriate behavior?

What are the discipline practices in your home? Please give specific examples for each child.

CS 0172 (2004/11) ___ Worksite File - Foster Home File File Section 3

     ___ Worksite File - Child’s File File Section 1

     Page 2 of 4

lll. Home and Community

    Please describe the sleeping arrangements of all foster children.

    Name Sleeping Arrangement

Please identify equipment on home adaptations (bar, ramps, etc.) which facilitate the management and care of a

    physically or mentally challenged child.

    What types of recreation are your family and foster child involved in, with whom and how frequently? Please give specific examples for each child.

Comment on how you and your family use relief services.

Have you completed the Safety Environment Assessment form (CS3606)? Yes No

Please summarize what you consider are the strengths and challenges for your foster family.

    Describe how you represent Foster Care professionally in the community. Some examples may be: providing training, board positions, committee involvement, recruitment, public speaking, writing articles, talking with neighbours or friends about the merits of fostering.

    Describe any problems encountered in the community with regards to fostering. (e.g. school, neighbours, police, health professionals) and how you have resolved these issues.

lV. Evaluation of Classification

    Indicate all training taken during the last year by each caregiver. Include the title and length of each course.

Describe your role(s) in providing input to and implementing the

     Concurrent Plan Transition to Independence Plan Secure Services Plan during the past year (e.g. design, leadership, initiating service decisions, assessments, case conferences, court etc.).

    Describe the format, content and frequency of your recording practices, and where your records are stored. Please be prepared to share them with your Foster Care Caseworker.

    Please use this space to comment on a particular skill or technique you have developed, or any unusual situation you have had to deal with and wish to share.

Review Learning Plan/Goals

Establish Goals for Upcoming Year

    Foster Parent Signature Date (yyyy/mm/dd) Foster Parent Signature Date (yyyy/mm/dd)

Foster Caseworker Signature Date (yyyy/mm/dd) Foster Care Agency Signature Date (yyyy/mm/dd) (if applicable)

CS 0172 (2004/11) ___ Worksite File - Foster Home File File Section 3

     ___ Worksite File - Child’s File File Section 1

     Page 3 of 4

Evaluation by Child(ren)’s Caseworker(s)

    This report will be completed by Child, Youth and Family Enhancement Act Workers who currently have had children placed in a foster home during the Annual Assessment period. It assists the Foster Care Worker in the ongoing

    assessment and evaluation of our foster homes. Thank you for your cooperation in the completion of this form.

1. Name of Foster Parent(s)

2. Name(s) of Child(ren) currently placed

    3. Is this foster home meeting the needs of current placements? Please explain.

    4. Identify what casework supports have been provided to the foster family.

5. Foster family’s ability to work with caseworker, natural family, adoptive family, involved professionals.

    6. Identify foster parents strengths/abilities and areas for development.

    7. What is/are the natural/adoptive families impressions of this foster home?

8. Please comment on the child(ren)’s impressions of this foster home?

9. Caseworker’s impression of this foster home and other comments.

    Caseworker’s Signature Date (yyyy/mm/dd)

     10. Please return this completed form to: Worksite Address

    Foster Care Worker’s Name (PRINT)

    Worksite Name

CS 0172 (2004/11) ___ Worksite File - Foster Home File File Section 3

     ___ Worksite File - Child’s File File Section 1

     Page 4 of 4

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