State of Arizona

EXHIBIT A Department of Child Safety

Office of Procurement & Contracts
3003 N. Central Ave., 20th Fl.
Parenting Plan Phoenix, AZ 85012

Check One: ☒ Initial with parent/caregiver ☐ Final Plan with DCS Date: ________
Date of Intake: 6/3/2021
Participant Name: PID :
ADCS Specialist:
Parent Aide:

Reason for Removal:

Court Orders: Next CFT Date:

Identified Protective Capacities: (listed on the addendum)

Please check all diminished protective capacities and the Contracted Provider will assist the parent in enhancing them.

Capacity Categories and Types

Behavioral Cognitive Emotional

the childExpresses love, empathy, sensitivity to

protectionPlans and Articulates plans for
GuardianAdaptive as a Parent/Legal

Is aligned and supports the child

Is positively attached with child
childSets aside own needs for

Demonstrates adequate skills

Meets own emotional needs

Understand protective role
Recognizes child's needs
Is intellectually able
Recognizes threats
Controls impulse

Takes actions

Is self-aware

Adults Is resilient
Is tolerant
Is stable

Visitation Requirements: (ba/sed on the addendum)

Visitation Plan and Location

Revised 04/2017
 State of Arizona
EXHIBIT A Department of Child Safety
Office of Procurement & Contracts
3003 N. Central Ave., 20th Fl.
Parenting Plan Phoenix, AZ 85012

Reason(s) Home is not

approved:
30 day plan to have visits into
the home (Specific,
Me/asureable, Attainable,
Realistic, Timely):
☐ Family needs more than 30 days. DCS will reevaluate at the Midpoint Meeting

Parent/Caregiver’s Input
1. Please describe your relationship with your child(ren)?Loving, caring, good.

Click here to enter text.

2. Please describe your relationship with the other parent/caregiver? Excellent live together happy

Click here to enter text.

3. What is the date and nature of the last contact between you and child(ren?

6/3/2021 Click here to enter text.

4. What do you hope to gain from engaging in the Parent Aide service? Kids back and to learn about
parenting

Click here to enter text.

5. Are there any issues or special needs that you or your child(ren) have that may impact visits?

Click here to enter text.

6.

Caretaker Protective Capacities Target Completion

Revised 04/2017
 State of Arizona
EXHIBIT A Department of Child Safety
Office of Procurement & Contracts
3003 N. Central Ave., 20th Fl.
Parenting Plan Phoenix, AZ 85012

Date Date
Protected capacities to be enhanced? (current behavior):

Click here to enter text.

Action Items (Specific activities one will work on to accomplish change)

a. Click here to enter text.

b. Click here to enter text.

Desired Outcome(s) (Behavioral changes display)

a. Click here to enter text.

b. Click here to enter text.

Parent Aide will work with the family by:

a. Click here to enter text.

b.

c. Parent Aide will utilize Parenting Wisely Curriculum

Target Completion
Caretaker Protective Capacities Date Date
Protected capacities to be enhanced? (current behavior):

Click here to enter text.

Action Items (Specific activities one will work on to accomplish change)

a. Click here to enter text.

b. Click here to enter text.

Desired Outcome(s) (Behavioral changes display)

a. Click here to enter text.

b. Click here to enter text.

Parent Aide will work with the family by:

Revised 04/2017
 State of Arizona
EXHIBIT A Department of Child Safety
Office of Procurement & Contracts
3003 N. Central Ave., 20th Fl.
Parenting Plan Phoenix, AZ 85012

a. Click here to enter text.

b. Click here to enter text.

Target Completion
Caretaker Protective Capacities Date Date
Protected capacities to be enhanced? (current behavior):

Click here to enter text.

Action Items (Specific activities one will work on to accomplish change)

a. Click here to enter text.

b. Click here to enter text.

Desired Outcome(s) (Behavioral changes display)

a. Click here to enter text.

b. Click here to enter text.

Parent Aide will work with the family by:

a. Click here to enter text.

b. Click here to enter text.

Additional Family Needs NOT related to Reunification

Mid-Point Meeting
Date and Location:

Revised 04/2017
 State of Arizona
EXHIBIT A Department of Child Safety
Office of Procurement & Contracts
3003 N. Central Ave., 20th Fl.
Parenting Plan Phoenix, AZ 85012

By Signing below, Parent(s) agree to participate in Parent Aide Services:

Parent Signature: Date:
Printed Name:

Parent Aide Signature: Date:

Printed Name:
ADCS Specialist
Date:
Signature:
Printed Name:

☐ DCS Specialist and/or designee was not able to attend the intake meeting.

The Contract requires a DCS Specialist signature and Supervisor signature approving the Parenting
Plan as a result of the DCS Specialist not being in attendance.
ADCS Specialist
Date:
Signature:
Printed Name:
Supervisor Signature: Date:
Printed Name:

Revised 04/2017