Family Name:

Maltreatment Element: What is the extent of the maltreatment?

Abuse
1 Physical
2 Sexual
3 Sexual Exploitation
4 Emotional
5 Bizarre Punishment
6 Violence

Neglect
10 Physical
11 Emotional
12 Safety
13 Medical
14 Lack of Supervision

Conflict
20 Parent to Child
21 Parent to Parent
22 Child to Child
23 Child to Parent

Surrounding Circumstance
30 Weapons Used
31 Threats
32 Alcohol or Drug Involved
33 Long Term
34 Isolated Incident

Custody Issues
40 Who has Custody
41 Who is Seeking Custody
42 What are Current Visitation Arrangements
43 CSE
Notes:

Child Functioning: How does the child behave?

Affect

Behavior Patterns

School

Child's Name:
Social Relationships

Emotional Patterns

1 Flat
Esteem *
2 Normal

Drugs

4
5
6
7
8
9
10
11
12
13
14
15

Alcohol *
Run Away *
Lying
Stealing
Destructive Behavior *
Fakes Illness
Craves Attention
Restless
Impulsive
Aggressive *
Cruelty *
Thumb Sucking

Physical Condition
70 Eating Habits *
Change
71 Sleeping Problems *
72 Nightmares *
73 Hygiene *
74 Menstruation
Height
75 Height
76 Weight
77 Hair Color
78 Eye Color
79 Scars or Marks

20 Truancy *
21
22
23
24
25

Tardiness
Suspension
Poor Grades
Behavior *
Homework

31
32
33
34
35
36
37
38

30 Problems with teacher

Shy
Sportsmanlike Conduct
Trust
Self Care Skills
Picks on Others
Picked on by Others
Fights with Others
Friendships *

Poor

Self-

Depression *
Temper Tantrums
Mood
Excessive Worry *
Suicidal Ideations *
Mutilation *
Perfectionism
Immature
Daydreams
Fantasizes
Blames Others
Attention Span
Fearful *
Defiant

Medical
80 Medications

Sexual Dynamics
100 Uncomfortable with Self

81
82
83
84

Pediatrician
Last Physical
Immunizations
Visual

101
102
103
104

Heightened Sexual Awareness * 121 Feeding Schedule

Uses Sexual Language *
122 Food Type
Inappropriate Masturbation *
123 Weight
Behaves Provocatively *
124
Length

85
86
87
88
89
90
91
92
93

Hearing
Recep/ Express Skills
Motor Skills

105
106
107
108
109
110

Dresses in Seductive Manner *

Knows Good / Bad Touch
Fire Starting *
Bedwetting *
Behavior Change *
Molestation History *

Enuresis
Encopresis
ADHD / ADD
Dental
Other

* denotes S/A Flag

Notes:

Adult Functioning: What are the pervasive behaviors of the adult?

Father

51
52
53
54
55
56
57
58
59
60
61
62
63
64

50

Mother

Baby Development
120

125
126
127
128
129
130
131
132
133

Diaper

Toilet Training
Verbal Skills
Walking / Crawling
Laugh / Cry
Teeth
Explores
Motor Skills / Grasp
Visual Skills
Hearing Ability
134 Cleanliness

Stress
1 No Stress Relief Techniques
2 No Anger Management

Stress
18 No Stress Relief Techniques
19 No Anger Management

Self
3 Inappropriate Self-Concept
4 Lacks Future Goals or Direction
5 Inability to Describe Self

Self
20 Inappropriate Self-Concept
21 Lacks Future Goals or Direction
22 Inability to Describe Self

Personal background
6 Poor Educational Background
7 Poor Employment History
8 Significant Health History / Medication
9 Excessive Alcohol / Drug Use
10 Failed to Benefit from Previous Therapy

Personal background
23 Poor Educational Background
24 Poor Employment History
25 Significant Health History / Medication
26 Excessive Alcohol / Drug Use
27 Failed to Benefit from Previous Therapy

Cooperativeness
11 Lacks Verbal Skills
12 Refuses to Cooperate / Communicate
13 Minimizes / Denies Problems
14 Contradicts Others Perception of Problem
15 Blames Others, Especially Children
16 Refuses Counseling
17 Refuses to Take Responsibility

Cooperativeness
28 Lacks Verbal Skills
29 Refuses to Cooperate / Communicate
30 Minimizes / Denies Problems
31 Contradicts Others Perception of Problem
32 Blames Others, Especially Children
33 Refuses Counseling
34 Refuses to Take Responsibility

Notes:

Parenting: What are the parenting practices in the family?

Family Roles
1 Father's Role
2 Mother's Role
3 Children's Role

Communication
30 Harsh
31 Mechanical
32 Speaks as Friends

Children's Peer Relationships

50 Knows Children's Friends
51 Approval of Friends
52 Controls Friendships

33
34
35
36
Structure
10 Limitations
11 Play Areas
12 Dinner Time
13 Bath Time
14 Bed Time
15 Curfew
16 Phone Privileges
17 Child Runs Home

Listens
Interrupts
Degrades
Uses Sexual Names

Chores
40 Age Appropriate
41 Too Many
42 No Responsibilities
43 Interfering

53 Prevents Friendships

Discipline / Punishment
60 Lengthy Grounding / Restriction
61 Inappropriate Physical Punishment
a. Face / Head/ Mouth Slapping
b. Bare Skin or Non-Buttocks Spanking
c. Administered by Wrong Parent
d. Public Spanking
e. Uses Objects to Spank
f. Leaves Bruises / Scars
62 Inappropriate Withholding Privileges
63 Age Inappropriate Time-Out
64 Uses Physical Punishment as a First Resort

Notes:

Family History: What is the recent history of the adults?

Father's History
1 Harsh Parenting Practices Used
2 Abusive Childhood
3 No Childhood
4 Alcohol / Drug Abuse
5 Sibling Difficulties
6 Several Relocations

Mother's History
7 Harsh Parenting Practices Used
8 Abusive Childhood
9 No Childhood
10 Alcohol / Drug Abuse
11 Sibling Difficulties
12 Several Relocations

Marriages
20 First Marriage: 19____ to:
21 Divorce/ Separation: 19___
22 Second Marriage: 19___ to:
23 Divorce/ Separation: 19___
24 Additional
to:
Court Actions
50 Family Court
Custody Matters
Visitation Matters
PFA
51 Superior Court

Characterization of Marriages
30 Domestic Violence
31 Alcohol Abuse
32 Drug Abuse
33 Sexual Abuse
34 Child Abuse
Family Births or Deaths
52 Who
53 When
54 Circumstance
55 Effect on Family

Criminal History
40 Who
41 Why
42 Prob/Parole Officer

Previous DFS Involvement

60 When
61 Why
62 Outcome

Notes:

Interpersonal Relationships: Quality of adults relationships

Friendships
1 Lacks Personal Friendships
2 Abusive
3 Alcohol / Drug Involved
4 Non Supportive
5 Refuses
Notes:

External Group Involvement

20 No Outside Support Network
21 Minimally Supportive
22 Too Involved
23 Destructive to Family Dynamics
24 Controlling

Religious Affiliations
30 Children are Resistant
31 Parents are Resistant

Demographics: What is the condition of the familys environment?

Home
1 Too small
2 Not Enough Bedrooms
3 Inappropriate Sleeping Arrangements
4 Poor / Unhealthy Cleanliness
5 Dangerous Environment
6 Inadequate Heat
7 Inadequate Electrical
8 No Toilet Plumbing
9 No Hot Water
10 Inadequate Food Supply

Financial
20 Lacks Adequate Family Income
21 Excessive State Assistance
22 AFDC / WIC / Stamps
23 Child Support Payments Not Received
24 Disability
Miscellaneous
30 No Transportation
31 No Telephone
32 Isolated Location

Notes:

Family Functioning: How does the family function as a unit, interact and communicate with
each other?
Parents Towards Children
Children Towards Parents
1 No Apparent Bonding
20 No Apparent Respect
2 Surface Interaction
21 Unprovoked Anger
3 Anger
22 Excessively Aggressive
4 Inappropriate Communication
23 Physical Abusiveness
5 Aggressive
24 Constantly Curses
6 Children are Treated as Property
7 Children are treated as Labor Force
8 Hides Child
9 Controls Every Action
10 Abdicates Responsibilities to Child
Notes:

Children Toward Children

30 No Apparent Bonding or Interaction
31 Unprovoked Anger
32 Excessively Aggressive
33 Physically Abusive

Extended Family Relationships: What is nature of extended familys support?

Father's Family
Relations
1 Father
2 Mother
3 Sister(s)
4 Brother(s)

Mother's Family
1A Step-FA
2A Step-MO

Supportiveness
5 Not supportive
6 Conflictual
7 Interferes With Family Matters
8 Refuses to Assist Family
Notes:

Relations
9 Father
10 Mother
11 Sister(s)
12 Brother(s)

Characterization of Family
13 Physically / Sexually Abusive
14 Alcohol / Drug Abuse
15 Violence
16 Criminal Involvement

9A Step-FA
10A Step-MO

Family Response: How does family perceive DFS intervention? What services can DFS provide
the family?
Therapeutic
1 Psychological
2 Psychiatric
Program
3 Drug Rehabilitation
4 Family Counseling
5 Day Treatment
6 In Patient Care
7 A/A
8 Pastoral Counsel

Parenting Skills/ Assistance

10 Parent Troubled Teens Classes
11 Parenting Skills Class

Medical Needs
20 Child Watch
21 Home Health Nurse

Child Needs
30 YMCA
31
Big

12 Parent Aid
13 Temp Relative Placement
14 Domestic Violence Education

22 DPH Visiting Nurse

32 Local Scared Straight
23 Delaware Perinatal
33 School Mentor
24 Matthew Smith Transport 34 Day Camp
25 CMH
26 YRS

Notes:

Domestic Violence History

Y

Threatened or has threatened suicide or homicide

Has made previous suicide attempts

Has injured victim in the past

Has used a weapon to threaten or assault

Has killed or injured family pets

Has imprisoned or held victim hostage

Has destroyed personal property (especially those of sentimental value)

Has acknowledged or reported history of drug use

Bother/Sister

Has previously engaged in abuse or violence and was not reported

Is excessively jealous or blames victim

Is hostile, angry, out of control

Is not fearful of consequences

Is obsessed with victim

Is controlling and resents interference

Has access to weapons

Is faced with divorce or separation

Has engaged in escalating violence

Has assaulted victim while she was pregnant

Disables vehicle to control victim

Accuses victim of having affairs

Refuses the victim to have phone calls or friends

Tells victim she cannot get along without him

Tells victim she is useless, calls names

Threatens to injure children

Has abused children in the past

Has a history of sexual deviance

Apologizes after assaulting victim

Brings victim gifts and tries to make amends

Promised never to be abusive again

Victim feels tension build before an incident

Drinks or uses drugs prior or during to violent incident

Stalks victim even when there is a No Contact Order

Has history of psychiatric illness

Has history of alcohol abuse

Has been arrested previously for domestic violence

Experienced violence as a child

Was involved in a violent relationship with another person

VLR

LR

2.7

13.5
5

LMR

MR

27.0

40.5
10

MHR
54.0
15

HR
67.5
20

HEHR
81.0
25

EHR
99.9
30

RISK:
37

Questionnaire on Drinking Habits

YES

NO

1. Do you enjoy a drink now and then?

2. Do you feel you are a normal drinker?

3. Have you ever used other drugs such as cocaine, marijuana, heroin?

4. Have you ever had:

a) a blackout from substance use
b) an injury after using alcohol or substance
c) a sick feeling after you stopped using
d) crawling feeling on your skin after stopped using
e) used needles to inject drugs
5. Have you ever awakened the morning after drinking or using
drugs the night before and found you could not remember a part
of the evening?

2
2
2

0
1
0
2
0

0
0

6. Does your spouse or other close relation worry or complain

about your drinking or other substance use?

7. Can you stop drinking without a struggle after one or two

drinks?

8. Do you feel guilty about your drinking or drug use

9. Do friends or relatives think you are a normal drinker?

10. Are you able to stop drinking or using drugs when you want to? 0

11. Have you ever attended a meeting of A/A or N/A?

12. Have you ever gotten into a fight when drinking or using drugs?1

13. Has your drinking or drug use ever created problems

between you and your spouse or other relative?

14. Has your spouse or other person ever tried to go to anyone

for help about your drinking or drug use?

17. Have you ever lost a job because of your drinking or substance use?

18. Have you ever neglected your obligations, your family, or

your work for two or more days in a row because you
were drinking or using drugs?

15. Have you ever lost a friend because of your drinking or substance use? 2
16. Have you ever gotten into trouble at work because of your
drinking or drug use?

19. Do you drink before noon fairly often?

20. Have you ever been told you have liver trouble?

21. After heavy drinking, have you ever had severe shaking, tremens,
heard voices, or seen things that werent there?

22. Have you ever gone to anyone for help about your drinking?

23. Have you ever been hospitalized because of drinking?

24. Have you ever been a patient in a psychiatric hospital where

drinking was part of the problem?

25. Have you ever seen a doctor, clergyman, social worker, or other
health care professional for emotional problems, when drinking
was part of the problem?

26. Have you ever been arrested for drunken driving, DUI? # times

27. Have you ever been arrested, or taken into custody, even for
a few hours, because of other drunken behavior? # times

1 -3
4
5>

Non-diagnostic
Suggestive
Diagnostic