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The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be directed to the Director, Child Welfare, (250) 953-4737, PO Box 9745, Stn Prov Govt, Victoria, B.C. V8W 9S5, email: MCF.StandardsPolicy@gov.bc.ca

Caregivers may be requested by their Resource Worker to complete a report each month for each child/youth that currently resides in the Caregiver's home. Once the report has been completed, the Caregiver provides the report to their Resource Worker. Please do not send this report to the Resource Worker via email. If you have any questions about completing this form, please contact your Resource Worker.

Report Date

MM/DD/YYYY

Legal First Name:

Legal Last Name:

Preferred First Name:

Age:

Placement Date:

MM/DD/YYYY

Relationship

First Name

Last Name

Phone Number

Relationship

First Name

Last Name

Phone Number

Child's/Youth's Attendance/Participation in Cultural, Spiritual, Social and Recreational Events/Activities

Please comment on any events/activities such as family/social events, ceremonies/religious services, community/ethnic events, learning events, recreational, Indigenous cultural events and involvement with Indigenous community, if appropriate.

Family and Relationships

Please comment on and list below any contact/visits with family (including siblings, extended family, Elders, and significant others the child/youth is not living with but has contact with). Additionally, document the child’s/youth’s emotional state before/after visits, transportation, and any safety concerns or restrictions related to contact with family or significant others in relation to the child/youth's emotional or physical safety. Please add any successes and/or goals achieved.

Name of Family Member

(e.g., mother, father, sibling, aunt, uncle)

Date

MM/DD/YYYY

Location

Comment/Frequency

Child's/Youth's Appointments

Please provide a list of all the child’s/youth’s appointments (e.g., physical, emotional, mental, spiritual, behavioural and

developmental, including mental health clinicians and traditional healers).

Date

MM/DD/YYYY

Name of Professional

Services Accessed

Contact Information

Changes in Care Home, Illnesses and Accidents

Please include information about any changes in the home, including new residents, illnesses and accidents.

New Resident Name:

Age:

Child’s/Youth's Health, Behavioural, & Emotional Needs/Changes

Please comment on any positive aspects and/or challenges that have had an impact on the child/youth. For example, coping skills, self-care, new skills learned, growth, transition to independent living skills, physical, behavioural, emotional health and needs. Include, if appropriate, any developmental disabilities and how these have impacted the child/youth and how you are addressing the child’s/youth’s challenges. Also, please add any success/achievements, if appropriate.

Child’s/Youth’s School, Daycare, Work, & Day Programs

Please comment on any successes/achievements and concerns/changes the child/youth has experienced within the last month. Also include attendance at child/youth programs, sports, extra-curricular activities, cultural activities, school, and involvement with school staff, Aboriginal Liaison Worker or other specialized staff.

Has there been any involvement with the police/courts/lawyers since your last report?

How is the child/youth responding to their permanency plan?

If the child/youth is Indigenous, how is their family and/or community involved in supporting the transition?

Include incidents where the child/youth is absent and/or has stayed overnight outside the Caregiver’s home. Additionally, include where the child/youth has stayed with an alternate Caregiver (include the name of the alternate Caregiver).

Date(s)/Time Left

Caregiver's Home

(MM/DD/YYYY) and (AM/PM)

Date(s)/Time Returned

to Caregivers Home

(MM/DD/YYYY) and (AM/PM)

Comment

(If appropriate, please include the name of the Alternate Caregiver).

Date

Time

Date

Time

Approved Relief

Please ensure that both a Criminal Record Check and Relief Care Provider Assessment Checklist is on file, as required. Please

provide the full name of who provided care, date, and location.

First Name of Person Who Provided Care

Last Name of Person Who Provided Care

DateMM/DD/YYYY

Criminal Record Check

Relief Care Provider Assessment Checklist

Comment

Caregiver Observations

Please comment on the observable behaviours of the child/youth. For example, increase/decrease in behaviours, routines or circumstances, verbal/physical/sexual/self-destructive behaviours, alcohol/drug use, self-care/coping skills, interaction with others, and care of physical space.

Additional Comments/Special Alerts:

Caregiver's Name (Please Print):

Date:

MM/DD/YYYY

Caregiver's Signature

Caregiver provides their Resource Worker with the original monthly report.

MCFD Documentation Mangement

• The original signed Monthly Caregiver Report is filed in RE Section 7 - Child in Care Information.

• Child’s Worker/Guardianship Worker is provided with a copy of the report and it is filed in CS Section 5 – External Reports.

• If requested, provide a copy of the completed report to the Caregiver.

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Caregiver Monthly Report

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Identity (including Family and Social Relationships, Culture and Religion)

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