Form Rfa-04 - Resource Family Risk Assessment
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2STATE OF CAIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
RESOURCE FAMILY APPROVAL
RESOURCE FAMILY RISK ASSESSMENT
RESOURCE FAMILY INFORMATION
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DATE:
APPLICANT’S NAME
ASSIGNED SOCIAL WORKER:
RISK ASSESSMENT GUIDELINES
Prior to the approval of a Resource Family, the social worker shall complete a caregiver risk assessment; which, at a minimum,
considers the components listed below. Results of the risk assessment shall be consistent with the factors listed in sections
16519.5(d)(1)(A-D) of the Welfare and Institutions Code (Welf. & Inst. Code).
The results of this risk assessment do not necessarily determine the final approval or disapproval of a potential resource family.
I
Physical Health
Comments:
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Mental Health
Comments:
I
Substance Use/Abuse
Comments:
I
Family/Domestic Violence
Comments:
History
RFA-04 (11/13)
RESOURCE FAMILY RISK ASSESSMENT
PAGE 1 OF 2
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Parent category: Legal