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�U <br /> ASSESSMENTS <br /> Client : File #: open: Close: Counselor: <br /> FAMILY RISK/PROTECTIVE FACTORS <br /> Instructions: When a hsklprotective factor is assessed, place a checkmark in the box if the factor needs to be addressed. Upon <br /> completion (a risk factor that is no longer a risk, or a protective factor that has been enhanced) write, 'completed" in the appropriate box. (if <br /> a risk/protective factor does not need to be addressed, the box will be blank) <br /> RISK FACTOR INITIAL 3 MONTH 6 MONTH 9 MONTH ASSESS. AT <br /> ASSESS. DATE: ASSESS. DATE: ASSESS. DATE: ASSESS. DATE: COMPLETION <br /> 1. Additional parenting knowledge/ <br /> skills needed <br /> 2. Parents history of abuse as a <br /> child <br /> 3. Parent/s history of substance abuse <br /> 4. Parent/s history ofinental health issues <br /> 5. Domestic Violence — Past/Present <br /> (Victim/Per etrator) <br /> 6. Inability to meet basic needs <br /> 7. Teen, young or non-traditional <br /> arent <br /> 8. Lack of support system <br /> 9. Parents/Children with physical <br /> handicaps or other diagnosable <br /> conditions <br /> 10. Other <br /> PROTECTIVE FACTOR INITIAL 3 MONTH 6 MONTH 9 MONTH ASSESS. AT <br /> ASSESS. DATE: ASSESS. DATE: ASSESS. DATE: ASSESS. DATE: COMPLETION <br /> LHousing stability <br /> 2. Delay 2f subsequent pregnancy <br /> 3. Enrollment in childcare <br /> 4. Enrollmentin healthcare <br /> 5. Child receives routine medical care <br /> 6. Livable wage employment <br /> 7. Active participation in child's <br /> school <br /> 8. Positive Family Communication <br /> 9. Constructive use oftime <br /> 10. Supportive adults outside ojfamily <br /> AAPISCORES <br /> AAPI-A (Pre) AAPI-B (Post) <br /> A B C D E A B C D E <br /> A B C D E A B C D E <br /> Word/S/SF Forms/Family Risk/Protective Factors Assessment Form/Rev. 02/05 <br /> 26 <br />