West Virginia Department of Health and Human Resources

Protective Capacity Family Assessment

And
Family Case Plan
__________________________________________________________________
Family Name

FACTS Case #

Worker Name

Date

Case Plan Start Date

Anticipated Case Plan Evaluation Date:

CHILD INFORMATION
List all children in the household.
Child Name

Date of Birth

1
2
3
4
5

CAREGIVER(S) AND OTHER ADULT(S) INFORMATION

List all Caregivers and other Adults the household
Name

Date of Birth

Relationship to child

Section A. Protective Capacity Family Assessment Contacts:

Record the protective capacity family assessment intervention process below: identify dates,
sources of information, PCFA intervention stage : i.e. Introductory, Discovery or Case Planning
and Change related to the contact, general information and challenges to completing the
protective capacity family assessment; also include any changes in safety analysis and
justification when the PCFA protocol was not followed.

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CONTACTS

Name

PCFA Intervention
Stage

Time/date

Brief summary of contact (as

appropriate)

Section B. PCFA Introduction Stage: Reason for Ongoing CPS

Involvement
Identify and describe each impending danger threat determined during the Family Functioning
Assessment and confirmed during the Protective Capacity Family Assessment.
Impending
Danger(s)

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Description
(Family Specific)

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Describe the caregivers reaction and perspective regarding the identified impending danger.

Section C. PCFA Discovery Stage-Determining what must change

Family Outcome: The outcomes must use family specific language but should encompass one
or both of the following criteria: (1) The caregiver/parent will demonstrate enhanced behavioral,
emotional and/or cognitive protective capacities which will ensure their childs safety or (2) the
child will be safe as demonstrated by the caregiver/parents enhanced protective capacity which
will eliminate or reduce the impending danger threat to the child. List the outcome below.
a.

Caregiver #1: _________________________

1. Goals: Describe the cognitive; emotional; and/or behavioral caregiver protective capacities
that must be enhanced to create a safe home elicit caregiver perceptions, language and
then behaviorally state the measurable goal. Achieving the goal will move the caregiver closer
to achieving the desired outcome-a safe and permanent home for the child(ren).
a.
b.
c.
d.
2. Status of Motivational Readiness (Specifically describe where individual family members are
in relationship to the stages of change. The stages of change are: Pre-Contemplation,
Contemplation, Preparation, Action and Maintenance)

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3. Identify and specifically describe currently existing/ enhanced caregiver protective capacities
and discuss how existing caregiver protective capacities can influence change.

4. Describe potential barriers to meeting client goals and outcomes.

Caregiver #2: _________________________

1. Goals: Describe the cognitive; emotional; and/or behavioral caregiver protective capacities
that must be enhanced to create a safe home elicit caregiver perceptions, language and
then behaviorally state the measurable goal. Achieving the goal will move the caregiver closer
to achieving the desired outcome-a safe and permanent home for the child(ren).
a.
b.
c.
d.
2. Status of Motivational Readiness (Specifically describe where individual family members are
in relationship to the stages of change. The stages of change are: Pre-Contemplation,
Contemplation, Preparation, Action and Maintenance)

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3. Identify and specifically describe currently existing/ enhanced caregiver protective capacities
and discuss how existing caregiver protective capacities can influence change.

4. Describe potential barriers to meeting client goals and outcomes.

Childs Goals: Identify and describe any service goals for child(ren) necessary to address their
individual needs. Goals are associated with child functioning, and must be specific and
measurable.
a.
b.
c.
d.

Section D. The Family Case Plan-Change Strategy

Identify treatment services necessary to facilitate targeted change associated with the
achievement of Caregiver Goals
Caregiver #1_______________

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1. Treatment Service: _________________________

Describe how the identified service is expected to assist the caregivers in accomplishing the
behavioral goals and in turn enhance meet the desired outcome
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________________
Treatment Service Agency if applicable: ____________________________
Individual Treatment Service Provider: ____________________________
Time Frame: Start Date: _____________

Frequency: _______________

Estimated End Date: ________________

2. Treatment Service: _________________________

Describe how the identified service is expected to assist the caregivers in accomplishing the
behavioral goals and in turn enhance meet the desired outcome
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________________
Treatment Service Agency if applicable: ____________________________
Individual Treatment Service Provider: ____________________________
Time Frame: Start Date: _____________

Frequency: _______________

Estimated End Date: ________________

Caregiver #2_______________
Treatment Service: _________________________
Describe how the identified service is expected to assist the caregivers in accomplishing the
behavioral goals and in turn enhance meet the desired outcome
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________________
Treatment Service Agency if applicable: ____________________________
Individual Treatment Service Provider: ____________________________

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Time Frame: Start Date: _____________

Frequency: _______________

Estimated End Date: ________________

Treatment Service: _________________________
Describe how the identified service is expected to assist the caregivers in accomplishing the
behavioral goals and in turn enhance meet the desired outcome
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________________
Treatment Service Agency if applicable: ____________________________
Individual Treatment Service Provider: ____________________________
Time Frame: Start Date: _____________

Frequency: _______________

Estimated End Date: ________________

Child ___________________
Service: _________________________
Describe how the identified service is expected to meet the childs needs and/or support the
parent in meeting the childs needs.
____________________________________________________________________________
____________________________________________________________________________
__________________________________________________________
Service Agency if applicable: ____________________________
Individual Treatment Service Provider: ____________________________
Time Frame: Start Date: _____________

Frequency: _______________

Estimated End Date: ________________

CPS Case Management Activities

Describe the case management responsibilities and activities CPS will be involved in to assist
the caregiver/family in achieving the goals and outcome identified in the Family Case Plan.

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Section E. Signatures
CPS Social Worker_______________________________________Date__________________
CPS Social Workers Phone #__________________________
Supervisors name and Phone #________________________
Parent/Caregiver_____________________________________Date______________________
Other Parent/Caregiver _______________________________Date______________________
Other Parent/Caregiver _______________________________Date______________________
Formal and Informal Service Provider(s)
___________________________________________________Date_____________________
___________________________________________________Date_____________________

Supervisor approval: _________________________________Date_____________________

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