Reunification and Therapeutic Family Time Plan

REUNIFICATION AND THERAPEUTIC FAMILY TIME PLAN
Name of Parent/Guardian*
First Last
Name of Child*
First Last
Are there other children?
- Yes
- No
Name of Child (2)
First Last
Name of Child (3)
First Last
Name of Child (4)
First Last
Date of Referral*
Date Format: MM slash DD slash YYYY
Date of Initial Meeting*
Date Format: MM slash DD slash YYYY
Names of Attendees*
Current Contact
Is phone communication currently occurring?*
- Yes
- No
If yes, with whom?*
Is written correspondence occurring?*
- Yes
- No
If yes, with whom?*
Therapeutic Family Time Schedule, location and transportation arrangements:*
Risk concern(s) and plans to address any identified concerns:*
Is there anyone who may not have contact with the child(ren) and why?*
Who will participate in Therapeutic Family Time?*
Name of contact person for rescheduling visits
First Last
Phone number of contact person for rescheduling visits*
Rescheduling procedures*
Scheduling barriers to consider?*
Special conditions affecting Therapeutic Family Time?*
(e.g., health, court orders, cultural issues, etc).
Parent/Guardian signature (1)*
Parent/Guardian signature (2)
Resource parent signature
DCF SW signature
RTFT worker signature*
Today's date*
Date Format: MM slash DD slash YYYY

REUNIFICATION AND THERAPEUTIC FAMILY TIME PLAN