474-000-323
I. CURRENT SITUATION
Circumstances precipitating placement
Location of child and length of time there
Situation and location of parents
Situation and location of siblings, if any
Description of placement resource, if known, or type of placement resource being sought
Child's attitude toward placement
Parents' attitude toward placement
II. CURRENT ASSESSMENT OF CHILD
Physical appearance: height, weight, hair color, eye color, skin color, distinctive marks
Current adjustment: behavioral, emotional, social skills
Relationship/interactions with parents, caregivers, siblings, peers
Health: diagnosis, treatment, prognosis
Special needs, if any
Education: grade, achievement, classroom behavior, relationship to teachers and classmates, extracurricular activities
Significant others in the child's life
III. ASSESSMENT OF PARENT(S) AND FAMILY
Cultural issues, including race
Physical description of parent(s) (appropriate for adoption)
Current functioning: education, employment, financial, parental, and social
Relationship/interactions with spouse, children, other significant family members
Health: physical and mental: diagnosis, treatment, and prognosis
Current and anticipated involvement with child
IV. BRIEF HISTORY OF CHILD AND FAMILY
Composition of the family, including birth order of siblings
Parent(s)' history: marriage(s), divorce(s), separation(s), death(s), employment, education, functioning within family group
Health: major illnesses, hospitalizations: at what age, duration, treatment, hereditary conditions, immunizations
Child's functioning: developmental problems and/or delays
Placement history, if any, including circumstances leading to initial request for placement
Involvement of relatives and/or significant others
V. PERMANENCY PLANNING
Permanent plan for the child
Anticipated duration of the proposed placement
Relationship of proposed placement to the permanent plan
Other options available for the child, if any
(Rev. March 14, 1988)