Scribd
Upload
19 views3 pages

CPS Supervised Visitation Checklist

The document is a form used by the Texas Department of Family and Protective Services for supervised visitation services, specifically focusing on sibling relationships. It includes checklists for observing child behavior, interaction, and reciprocity during visits. The form is intended to document observations and interactions between siblings to assess their relationships and behaviors in a supervised setting.

Uploaded by

rx4gdfnbyf
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
19 views3 pages

CPS Supervised Visitation Checklist

The document is a form used by the Texas Department of Family and Protective Services for supervised visitation services, specifically focusing on sibling relationships. It includes checklists for observing child behavior, interaction, and reciprocity during visits. The form is intended to document observations and interactions between siblings to assess their relationships and behaviors in a supervised setting.

Uploaded by

rx4gdfnbyf
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Texas Department of Family and Protective Services Form 3113

Child Protective Services – CPS March 2013


Supervised Visitation Services
Case Name: DFPS Case Worker: DFPS Supervisor:

Date: Day of Week: Actual Begin Time of Visit: End Time: __:__
Appointment Time: M T W TH F __:__ AM or PM
__:__ AM or PM

Visit Location: __CPS __Contractor Office Other:

Sibling Relationship Checklist

ID Child Name Age ID Child Name Age

A D

B E

C F

Child Behavior of child Yes No Identify the child that is the recipient of the behavior and
ID eg. Relative to Other describe the behavior observed with sufficient examples to
A, B Sibling(s) support your response.

Defends or protects

Recognizes siblings
distress and offers
comfort

Accepts comfort from


sibling

Teaches or helps

Initiates play

Responds to
overtures to play

Openly shows
affection

Misses sibling when


apart

Resolves conflict
through age-
appropriate
reasoning

Page 1 of 3
Texas Department of Family and Protective Services Form 3113
Child Protective Services – CPS March 2013
Supervised Visitation Services
Annoys, irritates or
teases

Shows hostility or
aggression

Blames or attempts
to get sibling into
trouble

Behavior sabotages
efforts to meet other
sibling’s needs

Interaction Observation Checklist

Identify the children and document any instances of interactions observed in which the child(ren)

Shared

Engaged in boisterous
play

Engaged in imaginative
activities

Joked or teased

Were secretive

Other

Identify the children and explain any marked differences between them in any of the following respects:

The roles they adopt

Activities and interests

Behavior

Personality

Other

Identify the children and document any observations of reciprocity, such as:

Pride in each other

Page 2 of 3
Texas Department of Family and Protective Services Form 3113
Child Protective Services – CPS March 2013
Supervised Visitation Services
Praise and criticism

Mutual help

Identify the children and document whether they model each other in the following ways:

Think they look alike

Imitate each other

Emulate the qualities they


like

Unite in face of problems

Other

Other observations:

Visitation Monitor Date

Date Sent to Caseworker Name: Manner Sent to Caseworker:


Caseworker:

End

Page 3 of 3

You might also like