Name of Family: OF IN-PERSON CONTACTS Date Person(s) Interviewed Location APPLICANT #1 PERSONAL CHARACTERISTICS: Describe how the Applicant presents him/her self and physical appearance. Briefly describe any special interests, hobbies, expertise, or talents the Applicant possesses. Also, report what the Applicant shared regarding his/her aspirations and goals in life. Describe Applicant’s conflict resolution and problem solving skills (how does applicant resolve problems? Coping skills?). Be concise and factual. HISTORICAL INFORMATION: Provide a concise factual description (preferably one paragraph) of the Applicant’s history that includes childhood family constellation, where raised, schools attended, religion, grief and loss, grief and loss of loved ones, resolving grief. APPLICANT #2 PERSONAL CHARACTERISTICS: Describe how the Applicant presents him/her self and their physical appearance. Briefly describe any special interests, hobbies, expertise, or talents the Applicant possesses. Also, report what the Applicant shared regarding his/her aspirations and goals in life. Describe Applicant’s conflict resolution and problem solving skills (how does applicant resolve problems? Coping skills?). Be concise and factual. HISTORICAL INFORMATION: Provide a concise factual description (preferably one paragraph) of the Applicant’s history that includes childhood family constellation, where raised, schools attended, religion, grief and loss, grief and loss of loved ones, resolving grief. APPLICANT(S) & PERSONS IN THE HOME MARITAL / PARTNER RELATIONSHIP (If applicable): Report all current and previous marriages/domestic partner relationships. Indicate name(s) and length of time of previous marriages/domestic partner relationships. Include how relationships were terminated, e.g., death, divorce, annulment, breakup, and dates. Identify any children born of these unions and describe their current situation. Include a sentence about how the spouse/partner describes the Applicant. SUPPORT SYSTEM: Church or community involvement, respite providers, close friends. Include your plan if you can’t/are unable to care for the child/children etc. MINOR SON(S) OR DAUGHTER(S): For each minor or daughter of the Applicants or either Applicant, provide the minor’s name, age, and gender followed by a description of their personality, interests, school, and living situation. Is the minor’s behavior age appropriate? Does the minor
Name of Family: OF IN-PERSON CONTACTS Date Person(s) Interviewed Location APPLICANT #1 PERSONAL CHARACTERISTICS: Describe how the Applicant presents him/her self and physical appearance. Briefly describe any special interests, hobbies, expertise, or talents the Applicant possesses. Also, report what the Applicant shared regarding his/her aspirations and goals in life. Describe Applicant’s conflict resolution and problem solving skills (how does applicant resolve problems? Coping skills?). Be concise and factual. HISTORICAL INFORMATION: Provide a concise factual description (preferably one paragraph) of the Applicant’s history that includes childhood family constellation, where raised, schools attended, religion, grief and loss, grief and loss of loved ones, resolving grief. APPLICANT #2 PERSONAL CHARACTERISTICS: Describe how the Applicant presents him/her self and their physical appearance. Briefly describe any special interests, hobbies, expertise, or talents the Applicant possesses. Also, report what the Applicant shared regarding his/her aspirations and goals in life. Describe Applicant’s conflict resolution and problem solving skills (how does applicant resolve problems? Coping skills?). Be concise and factual. HISTORICAL INFORMATION: Provide a concise factual description (preferably one paragraph) of the Applicant’s history that includes childhood family constellation, where raised, schools attended, religion, grief and loss, grief and loss of loved ones, resolving grief. APPLICANT(S) & PERSONS IN THE HOME MARITAL / PARTNER RELATIONSHIP (If applicable): Report all current and previous marriages/domestic partner relationships. Indicate name(s) and length of time of previous marriages/domestic partner relationships. Include how relationships were terminated, e.g., death, divorce, annulment, breakup, and dates. Identify any children born of these unions and describe their current situation. Include a sentence about how the spouse/partner describes the Applicant. SUPPORT SYSTEM: Church or community involvement, respite providers, close friends. Include your plan if you can’t/are unable to care for the child/children etc. MINOR SON(S) OR DAUGHTER(S): For each minor or daughter of the Applicants or either Applicant, provide the minor’s name, age, and gender followed by a description of their personality, interests, school, and living situation. Is the minor’s behavior age appropriate? Does the minor
dss_cws_153-c_rfa_cooperative_agency_assessment_report.docx