WPC  pk]"s(+\tQa [L>0:,P@E$nCv-Xw1ZȸJgZ4bn˪a?DD}WVK?fV] d9[۹QBn9u:P_8E74~ O(Q&3{E7/L [xm4?Bp#捉;Ӧp+ڒ4=㾩 +# OZ|>a2AWOyPe%kRu}9 \hlA y boi>+ZaBPψE[{y?IA?.zWGO/AR^r2m ^50_suTׁfFۀC3:Ɋ#8HZ" }SP͔YޖSʄ:F}1Fd:,ƌo akğ{)zK~7Wͻ93;+OgÅm#U&N % 0: fM aO fc ae fy a{ ^ w 4   m f a f a f a f a f3 a5 fI aK f_ aa fu aw f a f a f a f a f a f a f a f% a' f; a= NQ Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q BS S S S S S S S S S S S Bp p p p p p B' HP LaserJet 4100 Series PCL,,,,0(hH  Z6Times New Roman RegularX($USUS.,cTABLE ApmTABLE BbTABLE C7Z 4<74(Backup3|xUTABLE DTABLE E0TABLE FP,TABLE GcTABLE H0TABLE IcTABLE J0TABLE K\TABLE LhTABLE M9TABLE NZTABLE OH%TABLE PTABLE QH%TABLE RZTABLE SH%TABLE T d  d d !USUS.,  _h  ,X*ddd Xdd Xdd X$$, dd , dd , dd +  $   $HXXKansasSocialandRehabilitationServices qd ChildrenandFamilyServices ' ' 'qd 'D!D!C#CFS2030E qd ;#Rev.October2001  V!V!A#Page1of3" "#X.XH#ҼXX.*dd dd dd dd $$,X dd +  ${n{n $@   &5C%ҼChildinNeedofCareNonAbuseorNeglectAssessment#Ҽ%&5CG# ' '&5C%ҼSTATUS:#Ҽ%&5C# K>  &5C%ҼIdentifyingInformation:#Ҽ%&5CL# "#   "*l ddX dd X $$l,dd , dd ,dd ,dd ,Xdd ,dd ,Hdd +  $+ + $CaseName %Z  % -# Z -FACTSCase#: %Z  % 1' Z 1FACTSEvent#: (Z ( -#Z -SocialWorker %Z  % -# Z - +!  +DateofAssignment ,Z  , ;f* Z ;,4*(? 2   f 4,E *dddd  dd dd dd Xdd Xdd Hdd H $$,;dd ,dd ,4dd +  (   (&5C%Ҽ SectionI:PresentingProblem(Checkanythatareappropriate) #Ҽ%&5C # *lll  * P 1'3 & lll 1Withoutparentalcontrol *lll3 &  * 1' lll 1Childisunder10yearsofageandcommitsamisdemeanororfelony *lll  * 1' lll 1Absentfromchildshomewithoutconsentofparentsorcustodian *lll  * 1' lll 1Truancy *llll  *P  -#llll -Other(e.g.courtordered)    ,f ! ,D4*("  f 4D*dd;dd ;dd 4dd 4$$,;dd ,dd +  (" (&5C%Ҽ SectionII:Dangertoselforothers(Checkanythatareappropriate) #Ҽ%&5C3# *lll# *!P -#'$lll -Dangertoself(e.g.suicide,selfmutilation,refusesmedication,dangeroussexualbehavior,substanceabuse) 'lll'% ' -# &lll -Dangertofamily(e.g.aggressiveandabusivetofamilymembers,sexualabuseofsibling) 'llll ' ' -#(llll -Dangertoother(nonfamilymember) 5f$) 54*(*  f 4P*dd;dd ;dd $$,X dd +  $SF*SF $&5C%Ҽ SectionIII:ContributingFactors #Ҽ%&5C*# '+ 'Completethefollowingchildcontributingfactorsonlyforchild(_ren_)includedinthereport.",  "*lZddX dd X $$l,dd ,dd ,'dd , dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd +  (, (Ҽ %'- %Name  '. Name  '/ Name  '0 Name % '1 % @9 ChildContributingFactors * k^2 *Age !k^3 ! -#k^4 -Age !k^5 ! -#k^6 -Age !k^7 ! -#k^8 -Age !k^9 ! MCk^:  ?1.?M1. J@1;  ?1. ? JProblembehaviorsatschool %< %  =   >   ?  @6 @  @2@@2 I?0A  @2 @ ISchoolattendanceproblems %B %  C   D   E  A7 F  @3.@A3. J@17*G  @3. @ JDisturbedorunusualbehavior %7*H %  7*I   7*J   7*K  A7 7*L  @4.@A4. J@1{ nM  @4. @ JHasadevelopmentaldisability %{ nN %  { nO   { nP   { nQ  A7 { nR  @5.@A5. J@1!S  @5. @ JAssociateswithprimarilynegativepeers %!T %  !U   !V   !W  A7 !X  @6.@A6. J@1# Y  @6. @ JUsesdrugsoralcohol %# Z %  # [   # \   # ]  A7 # ^  @7.@A7. J@1G$:"_  @7. @ JPhysicalimpairmentsorpoorhealth %G$:"` %  G$:"a   G$:"b   G$:"c  A7 G$:"d   @8. @A8. J@1%~#e   @8.  @ JFamilyrelationshipsarestressfulandnon %~#f supportive %;&.$g %  %~#h   %~#i   %~#j  A7 %~#k  "@9."@A9. J@1'r%l  "@9. "@ JHasahistoryofdelinquency %'r%m %  'r%n   'r%o   'r%p  B8 'r%q $@10.$@B10. KA2(&r $@10. $@ KWasvictimofpastabuseorneglect %(&s %  (&t   (&u   (&v  B8 (&w &@11.&@B11. KA2*'x &@11. &@ KNopositivefamily/externalsupport %*'y %  *'z   *'{   *'|  B8 *'} (@12.(@B12. G=2K+>)~ (@12. (@ GOther(Specify) K+>)   K+>)   K+>)   K+>)   K+>)  B8 K+>) *@13.*@B13. G=2,* *@13. *@ GOther(Specify) ,*   ,*   ,*   ,*   ,* ,*   #Ҽ6#  /- _**d ddd dd 'dd ' dd dd dd dd dd dd dd dd Z$$*, dd , dd , dd +  $   $ HҼ '5( ' 'qd '##L#  CFS2030E  @;#Rev.October2001  @P!P!A#Page2of3"K>0 "#ҼH*#8+HҼ*dd dd dd dd $$,X dd +  $   $#ҼH ,#@   &5C%ҼChildinNeedofCareNonAbuseorNeglectAssessment#Ҽ%&5C>-# '}p 'STATUS:    IdentifyingInformation: "   "*lddX dd X $$l, dd , dd ,dd ,dd , dd ,dd ,dd +  $  $CaseName: %Z   % -#  Z -FACTS#: %Z   % 1' Z 1FACTSEvent# (Z  ( -# Z -SocialWorker: %Z[ N % -#[ NZ - +![ N +DateofAssignment ,Z[ N , ;f*[ NZ ;84*(   f 481*!"dd dd  dd dd dd  dd dd dd $$,X dd +  $     $ SectionIII:ContributingFactors continued " r  "*lZ ddX dd X !"$$l,dd ,dd ,dd ,Xdd ,dd ,dd ,dd ,dd ,dd ,dd ,dd +  (u h u h  (Ҽ %  %Name    Name    Name    Name %   % CaregiverContributingFactors *   *Age !  ! -#  -Age !  ! -# ! -Age ! " ! -# # -Age ! $ ! ND % ,@14.,@N14. KA2aT& ,@14. ,@ KSignificantlackofparentingskills %aT' %  aT(   aT)   aT*  B8 aT+ .@15..@B15. KA2, .@15. .@ KSocialrelationshipslackingorprimarily - negative %UH. %  /   0   1  B8 2 0@16.0@B16. KA23 0@16. 0@ KHistoryorcurrentsubstanceabuse %4 %  5   6   7  B8 8 1@17.1@B17. KA29 1@17. 1@ KIsemotionallyormentallyunstable %: %  ;   <   =  B8 > 2@18.2@B18. KA2!? 2@18. 2@ KDomesticrelationsproblems %!@ %  !A   !B   !C  B8 !D 3@19.3@B19. G=2eXE 3@19. 3@ GOther(Specify): eXF   eXG   eXH   eXI   eXJ  IZ8 eXK 4@20.4@I20. ]ZLAL 4@20. 4@Z ]Other(Specify): 4Z#!MZ 4 /ZNZ / 2Z!OZ 2 2Z!PZ 2 2Z!QZ 2 >f-RZ >H4*(S f  4#ҼZ5#H@**#$d ddd dd dd Xdd Xdd dd dd dd dd dd dd Z $$*,X dd +  $eXSeX $ &5C%ҼSectionIV:DescriptionandAnalysisofPresentingProblemsandContributingFactors#Ҽ%&5CB#  T Providedescriptionofthepresentingproblem,dangertoselforothers,andcontributingfactorsspecifyingcircumstances U andconditionsrelatedtosituation.Assessthefamilysabilitytouseitsstrengthsandresourcestomanageidentified eXV problemsandcontributingfactors.")W "*l%&ddX dd X #$$$l,X dd +  W   tX  'Y ' '1!$Z '("| [   (  (&b *l'(ddX dd X %&$$l, dd , dd , dd +  $   $HҼKansasSocialandRehabilitationServices qd ChildrenandFamilyServices ' ' 'qd 'D!D!C#CFS2030E qd ;#Rev.October2001  V!V!A#Page3of3" "*)*dd dd dd dd '($$,X dd +  ${n{n $#ҼHF#@   &5C%ҼChildinNeedofCareNonAbuseorNeglectAssessment#Ҽ%&5CsI# ' 'STATUS: K>  IdentifyingInformation: "   "*l+,ddX dd X )*$$l,dd , dd ,dd ,9dd ,dd ,dd +  $  $ҼCaseName: %ZeX  % -#eX Z -FACTS#: %ZeX  % -#eX Z -FACTSEvent# %ZeX % -#eXZ -SocialWorker: %Z  % -# Z - +!  +KK0DateofAssignment (Z  ( 8f' Z 8H4*(   f 4#ҼK#HM*-.dddd  dd  dd 9dd 9dd dd +,$$,X dd +  $e X e X  $&5C%ҼSectionIV:DescriptionandAnalysisofPresentingProblemandContributingFactorsContinued '  '#Ҽ%&5CO# Describeanyothersignificantfamilyorchildstrengthsorresourcesnotnotedabove: 5 (    ~        ;.  Z  (  Z (*l/0ddX dd X -.$$l,X dd +  $ $ PersonsContacted/Interviewed:  C6 Indicatedateandtimeofthecontact/interviewandwheretheresultsofthecontact/interviewcanbelocated.Ifany  persondeterminedrelevanttocasewasnotcontactedand/orinterviewed,documentwhynot.    !    yl!  f " ()#  f (*l12ddX dd X /0$$l,;dd ,,dd ,wdd ,zdd +  (# ( &5C%ҼSectionV:AssessmentConclusion#Ҽ%&5CT# *lllt$ * 1'%lll 1 \R#&  ?1.?\1. [QB'  ?1. ? [ NoProblemBehaviors .Therewerenosignificantbehaviorproblemsorcontributingfactorsidentified ( andthechildisnotadangertoselforothers. *CompleteFBASummary >l1#) > 1'!E 8* l 1  *   *  !lll * ! 1'!+lll 1 \R#!,N  @2.@\2. [QB!-N  @2. @ [ ProblemBehaviorsControlled .Significantproblembehaviorsandcontributingfactorswereidentified !. butfamilystrengthsandresourcesaresufficienttocontrolidentifiedproblemssuchthatthechildisnota c"V / dangertoselforothers. *CompleteFBASummary >l1#'#!0rrN > 1'!#!1 l 1  " 1   " 1  !llll " 1 ! 1'$t"2llll 1 \R#$t"3P  @3.@\3. [QB$t"4P  @3. @ [ ProblemBehaviorsPresent(child/youthisadangertoselforothers) .Significantproblembehaviors $t"5 wereidentified,andthereare NOT sufficientfamilystrengthsandavailableresourcestocontrolidentified G%:#6 problem. *CompleteFBASummary ;1# &$7ssP ; 1'!%#8 1  %#8   %#8  ( %#8  (4*(g'Z%9    4