REMEMBER: Sustaining: If an issue / behavior or event is not resolved and you are sustaining the Desk Guide Rating, please indicate how it affects the current functioning, ability to parent and how it would or does affect children in the home. Applicants’ Reducing: If an issue / behavior or event is partially resolved and you are reducing the Desk Guide Rating, please provide evidence that indicates how the issue / behavior or event was reduced, how it would or does affect current functioning, ability to parent, and how it would or does affect children in the home. Erasing: If you believe that an issue/behavior or event no longer affects the Applicants and you are erasing the SAFE Desk Guide Rating, please provide evidence to support your assessment that the issue/behavior or event no longer affects the current functioning or Applicants’ ability to parent. Never reference numbers or ratings in your narration. PSYCHOSOCIAL EVALUATION REPORT Applicant 1 Full Name HISTORY: Historical Information Evaluation Applicant 2 Full Name HISTORY: Historical Information Evaluation Applicant 1 Full Name PERSONAL CHARACTERISTICS: Evaluation If the Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical reasons for which they are being taken. Applicant 2 Full Name PERSONAL CHARACTERISTICS: Evaluation If the Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical reasons for which they are being taken. MARITAL / DOMESTIC PARTNER / CIVIL UNION RELATIONSHIP Evaluation Provide a brief description of the Marriage / Domestic Partnership / Civil Union highlighting their roles in the relationship, Applicant(s)’s division of duties, strengths, and skills.
REMEMBER: Sustaining: If an issue / behavior or event is not resolved and you are sustaining the Desk Guide Rating, please indicate how it affects the Applicants’ current functioning, ability to parent and how it would or does affect children in the home. Reducing: If an issue / behavior or event is partially resolved and you are reducing the Desk Guide Rating, please provide evidence that indicates how the issue / behavior or event was reduced, how it would or does affect current functioning, ability to parent, and how it would or does affect children in the home. Erasing: If you believe that an issue/behavior or event no longer affects the Applicants and you are erasing the SAFE Desk Guide Rating, please provide evidence to support your assessment that the issue/behavior or event no longer affects the Applicants’ current functioning or ability to parent. Never reference numbers or ratings in your narration. PSYCHOSOCIAL EVALUATION REPORT HISTORY: Applicant 1 Full Name Historical Information Evaluation HISTORY: Applicant 2 Full Name Historical Information Evaluation PERSONAL CHARACTERISTICS: Applicant 1 Full Name Evaluation If the Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical reasons for which they are being taken. PERSONAL CHARACTERISTICS: Applicant 2 Full Name Evaluation If the Applicant is taking any medications (prescribed or over-the-counter), please list and indicate the medical reasons for which they are being taken. MARITAL / DOMESTIC PARTNER / CIVIL UNION RELATIONSHIP Evaluation Provide a brief description of the Applicant(s)’s Marriage / Domestic Partnership / Civil Union highlighting their roles in the relationship, division of duties, strengths, and skills.
2402b.docx