San Luis Obispo County
Department of Social Services
RESOURCE FAMILY PLACEMENT REVIEW
Initial Placement 90 Day Check-In
Youth Name:
Caregiver Name(s):
Social Worker(s):
,
,
,
,
Please check the box next to your Role. I AM A:
Purpose: The intent of this review is to focus on the success and integrity of the Foster/Adoption placement
process.
INSTRUCTIONS:
Please respond to each item by checking next to the best description of YOUR experience or N/A if the question does
not apply to your placement at this time. Please think about the prompts listed as areas or activities to consider; they
help clarify the scope and intent of each item. Then, please elaborate or clarify any specifics of the activity that either
went well or needed improvement. Your comments are very important to this review process. Thank You.
#
1.
REVIEW QUESTIONS- Please check the most appropriate box
The Initial Placement went:
(Consider: availability of information [vital documents-Cencal Card, etc.] child’s personal belongings, manner of drop off,
knowledge of resources, completion of paperwork, follow-up contact, etc.)
Poorly
Some Bumps
Adequate
Mostly Smooth
Seamless and Smooth
N/A
Clarifying Comments, if any:
2.
The Quality of Information shared by participants was:
(Consider: information was timely, accurate, responses to questions/issues handled promptly, participants shared readily,
written reports were accurate and accessible, appropriate level of confidentiality honored, access to medical/school records,
etc.)
None
Poor
Adequate
Mostly Helpful
Very Helpful
N/A
Clarifying Comments, if any:
3.
The Communication of Participants was:
(Consider: timely and frequent contacts, returned phone calls, clear and relevant communications, support from Mentor, current
contact information, timely response to inquiries, respectful, etc.)
Very Poor
Lacking, Random, Occasional
Adequate
Kept Up to Speed
Super, Always on the
N/A
same page
Clarifying Comments, if any:
DSS CWS 790 (New 12/9/2013) Resource Family Placement Review-90 Day
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San Luis Obispo County
Department of Social Services
RESOURCE FAMILY PLACEMENT REVIEW
Initial Placement 90 Day Check-In
4.
The Professionalism of Participants was:
(Consider: available and participated in meetings, promptly followed through with responsibilities, punctual for meetings,
prepared for meetings, clear communication, felt respected, respected other’s input, worked collaboratively with team, etc.)
Non Existent
Very Poor
Adequate
Mostly Professional
Very Professional
N/A
Clarifying Comments, if any:
5.
The Services/Resources for Youth (including non-minor dependents) were:
(Consider: financial resources, mental health, health, educational services, extracurricular resources/activities-i.e. tutoring,
transportation, fees, timely and prompt services, accurate response/follow up/referrals for requests and/or information regarding
services, etc.)
Very Poor
Inconsistent
Adequate
Mostly Met
Excellent
N/A
Clarifying Comments, if any:
6.
The Nurturing Relationship was:
(Consider: attention given to youth’s culture/religion/ethnicity/lifestyle, advocacy for youth’s needs and interests, strong attempt
for inclusion in “normal family life” [holidays, vacations, activities], resources and support available by department,
age/developmentally appropriate opportunities to learn/practice life skills, able to maintain birth family relationships while in care,
etc.)
Very Poor
Lacking
Adequate
Most Needs Met
Full Inclusion in Family as Appropriate
N/A
Clarifying Comments, if any:
7.
The TDM (Team Decision-making Meeting) was:
(Consider: invited to attend TDM, timely TDM held, timely notification of meetings, input requested from participants, minimal
placement moves, etc.)
Poor
Some Bumps
Adequate
Mostly Smooth
Seamless and Smooth
N/A
Clarifying Comments, if any:
8.
The Concurrent Planning Process and Plan were: (concurrent plan is the back-up placement plan in case reunification
to birth family is not possible)
(Consider: concurrent plan was identified in a timely manner, plan was communicated to all parties, input requested from
participants, felt respected, kept informed of the status of plan, implemented as planned, etc.)
Poor
Some Bumps
Adequate
Mostly Smooth
Seamless and Smooth
N/A
Clarifying Comments, if any:
DSS CWS 790 (New 12/9/2013) Resource Family Placement Review-90 Day
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San Luis Obispo County
Department of Social Services
RESOURCE FAMILY PLACEMENT REVIEW
Initial Placement 90 Day Check-In
9.
The Birth Parent(s)/Caregiver(s)/Social Worker(s) Relationship was:
(Consider: reunification effort, family support, advocacy for family, visitation schedule, willingness to engage, follow through on
case plan expectations, etc.)
I AM THE:
Please check the box that corresponds to the quality of the relationships with the following participants
My Relationship with
Non-existent
Very Poor
Adequate
Good
Excellent
(below) was:
Birth Parent(s)
Caregiver(s)
Social Worker
Clarifying Comments, if any:
OTHER: comments, concerns, recommendations and/or commendations you feel would add to the improvement of the
Foster/Adoption Placement Process. Feel free to add more comment pages for general or specific items if
necessary.
I would like someone to contact me regarding this review, at:
PLEASE RETURN IN THE ENVELOPE PROVIDED, THANK YOU FOR YOUR INPUT!
Follow up done by:
Date:
COUNTY OFFICE USE ONLY:
DSS CWS 790 (New 12/9/2013) Resource Family Placement Review-90 Day
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N/A