Brief Intensive Services
Discharge Family Assessment
NCFAS-G
Today’s Date:
Child’s Name:
Admission Date:
Completed by:
Child’s DOB:
Discharge Date:
Reason for Referral:
For each of the domains listed below, provide the NCFAS-G overall rating:
A. Environment
Sub-scales to consider: housing stability, safety in the community, habitability of housing,
income/employment, financial management, food and nutrition, personal hygiene, transportation, learning
environment.
Clear
Strength
Mild
Strength
Baseline/
Adequate
Mild
Problem
Moderate
Problem
Serious
Problem
B. Parental Capabilities
Sub-scales to consider: supervision of children, disciplinary practices, provision of
developmental/enrichment opportunities, parent(s)/caregiver(s) mental health, parent(s)/caregiver(s)
physical health, parent(s)/caregiver(s) use of drugs/alcohol.
Clear
Strength
Mild
Strength
Baseline/
Adequate
Mild
Problem
Moderate
Problem
Serious
Problem
C. Family Interactions
Sub-scales to consider: bonding with child(ren), expectations of the child(ren), mutual support within the
family, relationship between parents/caregivers.
Clear
Strength
Mild
Strength
Baseline/
Adequate
Mild
Problem
Moderate
Problem
Serious
Problem
Adapted from the Initial Family Assessment for the NCFAS and NCFAS-R scales with permission from the developer, Institute for
Family Development.
S:\Secretaries\Briana\Forms\FBS Program Forms\Brief Intensive Services\Discharge Packet
Revised June 2012
D. Family Safety
Sub-scales to consider: absence/presence of physical abuse of child(ren), absence/presence of sexual
abuse of child(ren), absence/presence of emotional abuse of child(ren), absence/presence of neglect of
child(ren), absence/presence of domestic violence between parents/caregivers.
Clear
Strength
Mild
Strength
Baseline/
Adequate
Mild
Problem
Moderate
Problem
Serious
Problem
E. Child Well-Being
Sub-scales to consider: child(ren)’s behavior, school performance, child(ren)’s relationship with
parent(s)/caregiver(s), child(ren)’s relationship with sibling(s), child(ren)’s relationship with peers,
cooperation/motivation to maintain the family.
Clear
Strength
Mild
Strength
Baseline/
Adequate
Mild
Problem
Moderate
Problem
Serious
Problem
F. Social/Community Life
Sub-scales to consider: social relationships, relationships with child care, schools and extracurricular
services, connection to neighborhood, cultural/ethnic community, connection to spiritual/religious
community, parent(s)/ caregiver(s)’s initiative and acceptance of available help/support.
Clear
Strength
Mild
Strength
Baseline/
Adequate
Mild
Problem
Moderate
Problem
Serious
Problem
G. Self-Sufficiency
Sub-scales to consider: caregiver employment, family income, financial management, food and nutrition,
transportation.
Clear
Strength
Mild
Strength
Baseline/
Adequate
Mild
Problem
Moderate
Problem
Serious
Problem
H. Family Health
Sub-scales to consider: parent(s)/caregiver(s)’s physical health, parent(s)/caregiver(s)’s disability,
parent(s)/caregiver(s)’s mental health, child(ren)’s physical health, child(ren)’s disability, child(ren)’s
mental health, family access to health/mental health care.
Clear
Strength
Mild
Strength
Baseline/
Adequate
Mild
Problem
Moderate
Problem
Serious
Problem
Narrative Section
The narrative description should include any significant strengths and problem areas identified
in the sub-scales:
Adapted from the Initial Family Assessment for the NCFAS and NCFAS-R scales with permission from the developer, Institute for
Family Development.
S:\Secretaries\Briana\Forms\FBS Program Forms\Brief Intensive Services\Discharge Packet
Revised June 2012