CSO-2568

(03/21)

ARIZONA DEPARTMENT OF CHILD SAFETY

FAMILY CONNECTIONS OUTCOME-DRIVEN SERVICE PLAN

Date of FC service request

Family Information

Case Person Person ID FC Consultant (FCC)

FC Service Connection to Behavioral Change Goals in the DCS Case Plan (if applicable)
Identify the protective capacities and/or protective factors and the related behavioral changes from the DCS case plan that the FC service plan aims to achieve.
Summarize the discussion with the family members about the relationship between the FC Service Plan and the DCS Case Plan. If the DCS case is closing
with no case plan, this section is not applicable.

Family Strengths
Identify the individual, family, cultural, or community strengths identified in the Comprehensive Family Assessment that can be used or grown to achieve the
FC service plan goals.
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ARIZONA DEPARTMENT OF CHILD SAFETY
FAMILY CONNECTIONS OUTCOME-DRIVEN SERVICE PLAN

Identified FC Core Outcome(s)

Select the FC Core Outcome(s) that indicated a need for change focused work by check-marking the box. Complete the remaining sections if selected.

Social Support
Individualized Definition of the FC Core Outcome: (Using the FC Core Outcome definition(s) as a starting point, write an FC Core Outcome definition
that is tailored to the families’ needs and describes what must change to achieve the DCS case plan behavioral goals, strengthen family protective factors, and
enhance parental protective capacities.)

UBSMART Goal(s) that match this outcome:

Family Functioning
Individualized Definition of the FC Core Outcome: (Using the FC Core Outcome definition(s) as a starting point, write an FC Core Outcome definition
that is tailored to the families’ needs and describes what must change to achieve the DCS case plan behavioral goals, strengthen family protective factors,
and enhance parental protective capacities.)

UBSMART Goal(s) that match this outcome:

Family Resources
Individualized Definition of the FC Core Outcome: (Using the FC Core Outcome definition(s) as a starting point, write an FC Core Outcome definition
that is tailored to the families’ needs and describes what must change to achieve the DCS case plan behavioral goals, strengthen family protective factors,
and enhance parental protective capacities.)
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ARIZONA DEPARTMENT OF CHILD SAFETY
FAMILY CONNECTIONS OUTCOME-DRIVEN SERVICE PLAN

Identified FC Core Outcome(s) - continued

UBSMART Goal(s) that match this outcome:

Child Well-Being
Individualized Definition of the FC Core Outcome: (Using the FC Core Outcome definition(s) as a starting point, write an FC Core Outcome definition
that is tailored to the families’ needs and describes what must change to achieve the DCS case plan behavioral goals, strengthen family protective factors,
and enhance parental protective capacities.)

UBSMART Goal(s) that match this outcome:

Parenting Attitudes and Behaviors

Individualized Definition of the FC Core Outcome: (Using the FC Core Outcome definition(s) as a starting point, write an FC Core Outcome definition
that is tailored to the families’ needs and describes what must change to achieve the DCS case plan behavioral goals, strengthen family protective factors,
and enhance parental protective capacities.)

UBSMART Goal(s) that match this outcome:

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ARIZONA DEPARTMENT OF CHILD SAFETY
FAMILY CONNECTIONS OUTCOME-DRIVEN SERVICE PLAN

Identified FC Core Outcome(s) - continued

Managing Parenting Stress
Individualized Definition of the FC Core Outcome: (Using the FC Core Outcome definition(s) as a starting point, write an FC Core Outcome definition
that is tailored to the families’ needs and describes what must change to achieve the DCS case plan behavioral goals, strengthen family protective factors,
and enhance parental protective capacities.)

UBSMART Goal(s) that match this outcome:

Activities To Be Completed
Include activities for the family and the FC Consultant that will occur during weekly change-focused meetings, and activities to occur between home visits

Who What When

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ARIZONA DEPARTMENT OF CHILD SAFETY
FAMILY CONNECTIONS OUTCOME-DRIVEN SERVICE PLAN

Family Involvement in Service Plan Development

Describe the efforts to engage the family in the development of the plan and how input was obtained. Specify which family members were involved, their level
of involvement, and any requests for changes from the family members

Formal Services Needed or Referred

List the formal change or treatment oriented services to which the family was recommended or referred that are relevant to the identified FC Core Outcome(s)
and directed toward achievement of the UBSMART goal(s)

Additional Services
List all other services the family is currently and/or will be participating in that are not related to the identified FC Core Outcomes

Signatures

FC Consultant Name FC Consultant Signature Date

FC Supervisor Name FC Supervisor Signature Date

Family Member Name Family Member Signature Date

Family Member Name Family Member Signature Date

Family Member Name Family Member Signature Date

DCS Specialist (if applicable) DCS Specialist Signature Date

Equal Opportunity Employer/Program. The Department of Child Safety (DCS) prohibits discrimination in admissions,
programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics,
or retaliation or any other status protected by federal law, state law, or regulation. Reasonable accommodations to
allow a person with a disability to take part in a program, service, or activity are available upon request. To request
this document in alternative format or for further information about this policy contact your local office. TTY/TDD
Services: 7-1-1. Free language assistance for DCS services is available upon request. Ayuda gratuita con traducciones
relacionadas con los servicios del DCS esta disponible a solicitud del cliente.