Revised 2/26/08
Family Team Plan
Parents Names:
Child(ren)’s Names and Ages:
Meeting Date:
Participants (Family, Community and Staff)
Name
Relation to Child or Case
Revised 2/26/08
General Purpose of Meeting:
Family and CPS Concerns:
Family Strengths and Supports:
Revised 2/26/08
Goal #____
Statement of Goal:
How will this be accomplished? Who, What, When and How?_____________________
Revised 2/26/08
Goal #____
Statement of Goal:
How will this be accomplished? Who, What, When and How?_____________________
Revised 2/26/08
Goal #____
Statement of Goal:
How will this be accomplished? Who, What, When and How?_____________________
Revised 2/26/08
Miscellaneous:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Family Monitor:
CPS Monitor:
Name: ___________________________
Address: _________________________
_________________________________
Home phone: ______________________
Other: ___________________________
Name:________________________
Office: _______________________
______________________________
Office phone: __________________
Supervisor name and phone:
______________________________
Agreement by all:
I will protect the confidentiality and privacy of all parties involved in this case by
agreeing to refrain from discussing any information shared during the conference with
anyone other than the Conference participants or employees of the agencies they
represent.
Note: If any additional allegations of abuse or neglect arise during the Family Team
Meeting, the law requires that these allegations be reported to CPS.
Parent Signatures:
By signing this form, I am agreeing to perform the tasks specified in this plan, and
applying for the Title IV-A emergency assistance to help cover the cost of CPS’ services.
(Note: To function as an application for the Title IV-A emergency assistance, this form
must be signed by at least one parent or relative of the child.)
I understand that if I am unwilling or unable to provide a safe environment for my
child/ren, or follow the plan as described in this document, that CPS may have to file a
suit with the court to request court-ordered participation or to request court ordered
custody/removal of my children.
_____________________________________ ___________
Parent
Date
_____________________________________ ___________
Parent
Date
_____________________________________ ___________
Parent
Date
_____________________________________ ___________
Parent
Date
Revised 2/26/08
Participant Signatures:
We acknowledge we have participated in the Family Team Meeting and understand what
is being asked of us to do in this plan. By our signature, we are indicating that we care
about the issues discussed in this document and that we have agreed to assist and
participate in some way to help resolve the safety, risk and well-being issues for the
child/ren involved.
__Name (Print and sign)__________________________________ ___Date__________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
CPS Staff:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Facilitator:
________________________________________________________________________
________________________________________________________________________