Skip to content
217-717-4398
|
info@ilalliance.org
About
Who We Serve
History
Living with Mental Illness
Staff & Board
Resources
COVID-19
Referral Form
Are You in Crisis?
Video Resources
Mental Health
Disability
Juvenile Justice
Education
Child Welfare
Newsletters
Resource Manual
Events
Donate
Shop
Contact
Cart
A Shoulder to Lean On
PARENTS & YOUTH
PARENT’S SURVEY
PARENT NETWORK COMMITTEE
STATEWIDE FAMILY NETWORK
YOUTH
SUPPORT GROUPS
EDUCATIONAL PROGRAMS
TRAINING & TECHNICAL ASSISTANCE
PPSP Tool Kit
PPSP Tool Kit
yafa
2017-08-30T16:08:38+00:00
PPSP Tool Kit
Provided by Family Involvement Center
1
Family Assessment of Support Tool (FAST)
2
Family Assessment of Support Tool (FAST) Scorecard
3
Using Strengths for Self-Care
4
Life Balance Wheel
5
Needs Met Rating Tool
Staff member filling out the form
*
Polly Allen
Ulanda Hunter
Marithia Waters
Whitney Hudspath
Date Completed:
In Wraparound, we work together as a team to support your family. We will share the information on this form with your care coordinator. If you give us permission, the information on this form will also be combined with information from other families to be used in research to study how our services work and how we could make our services work better for families.
Name of person filling out form:
First
Last
Types of Support
When we face challenges, we often look to people in our lives for support. This is especially true when raising a child with emotional or behavioral needs. Who are those individuals that you have or could turn to for support?
Spouse/ Significant Other
Friend
Family Member
Neighbor
Faith Community
Other
Please Specify:
Presence of Support System
When I am experiencing difficult times, the important people in my life who provide me with support (such as family members, spouse, partner, friends or others) are…
Available to provide support to me most of the time and aware of my family’s situation
Available to provide support to me some of the time and aware of my family’s situation
Available to provide support to me some of the time, but not aware of my family’s situation
Never available to provide support to me/or I do not have any support people
Acceptance of Support System
When I think about how important people in my life react to …
a) My life choices and decisions, I feel
Accepted Most of the Time
Accepted Some of the Time
Judged Some of the Time
Judged Most of the Time
b) My child’s mental health needs, I feel
Accepted Most of the Time
Accepted Some of the Time
Judged Some of the Time
Judged Most of the Time
c) My parenting style, I feel
Accepted Most of the Time
Accepted Some of the Time
Judged Some of the Time
Judged Most of the Time
d) My child’s behavior, I feel
Accepted Most of the Time
Accepted Some of the Time
Judged Some of the Time
Judged Most of the Time
System Receptivity
When I’m working with the professionals in my child and family’s life…
a) I feel able to voice my ideas to the professionals
Most of the time
Some of the time
Rarely
Never
b) I am understood by professionals
Most of the time
Some of the time
Rarely
Never
c) My ideas are included in decision-making
Most of the time
Some of the time
Rarely
Never
Coping with Stress
When I think about the challenges I face…
a) I have the ability to deal with the things that happen to me
Strongly Disagree
Disagree
Agree
Strongly Agree
b) I can handle things when things get tough, because I know what I can do to make things better
Strongly Disagree
Disagree
Agree
Strongly Agree
c) I know that I can deal well with the unexpected
Strongly Disagree
Disagree
Agree
Strongly Agree
d) I often feel helpless when dealing with the problems of life
Strongly Disagree
Disagree
Agree
Strongly Agree
e) There is really no way I can solve some of the problems I have
Strongly Disagree
Disagree
Agree
Strongly Agree
For most of us, major life changes can create stress for our families. In this next section we are interested in hearing about the areas of your life and your family’s life that are likely to experience major change in the next 60 days.
Emotional
Safety
Family
A Place to Live
Cultural/Spiritual
Legal
Health
Social/Fun
School/Work
Other
SCORING SHEET
Presence of Support
Acceptance of Support
Coping with Stress
Expected Changes
PLANNED CONTACT
Supportive Contact: One face-to-face visit per month Weekly phone call and support group
Moderate Contact: Two face to face visit per month plus Supportive Contact
Intensive Contact: Weekly face to face contact with Supportive and Moderate Contact
Instructions:
Peer Parent Support Partner completes the Family Assessment of Support Tool (FAST) with the parent within 2 weeks of initial referral
Supportive Contact
0-10
Peer Parent Support Needed
Connect to Family Support Organization
Parent Peer Parent Support Partner
Weekly phone call
Moderate Contact
1-25 or total score between 6-7 on item V.
Peer Parent Support Needed
Connect to Family Support Organization
Peer Parent Support Partner
One face-to-face visit per month and weekly phone call
Intensive Contact
26-39 or total score between 8-9 on item V.
Peer Parent Support Needed
Connect to Family Support Organization
Peer Parent Support Partner
Weekly face-to-face visit and weekly phone call
Special note on scoring: Major changes or transitions can be a major source of stress on individuals. When the family has 4 or more major changes or transitions that they may go through in a 60 day period and they scored at the high end of a scoring range, go to the next contact level to determine the score range of support: Example: Mrs. Jones has 5 different major changes or transitions that are coming up and has a score of 10 or Supportive Contact. Because of the impending transitions, Mrs. Jones would move to the next contact level – Moderate Contact.
Parent Strength Survey
Parent’s Name:
First
Last
Peer Parent Support Partner Name:
First
Last
Date of Meetings:
Planned Date of Initial Plan of Care Meeting:
Skills
Skills for Taking Care of You
Self-Care Skills Evaluate your skill level to identify areas you can work on.
Taking Care of Your Physical Health
Power User
Highly Skilled
Adequate
Need Help
Taking Care of Your Emotional Health
Power User
Highly Skilled
Adequate
Need Help
Taking Care of Your Spiritual Health
Power User
Highly Skilled
Adequate
Need Help
Taking care of Thoughts & Feelings:
Power User
Highly Skilled
Adequate
Need Help
Other: Please list
System Navigation and Team Participation Skills
Rate your skill level in each of these areas
Active listening - Giving full attention to others without interrupting.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Negotiation - Finding common ground between opposing parties.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Conflict resolution - Bringing people together and reconciling differences.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Service orientation - Actively looking for ways to help others.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Persuasion - Persuading others to change their minds or behavior.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Delegating - Matching tasks to people with the appropriate skills and interest to do them.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Coordination - Adjusting actions in relation to the actions of others as necessary.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Instructing - Teaching others to do something, making sure that they comprehend.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Speaking - Talking to others to convey information effectively.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Written Communication - Taking time to write clearly and respond appropriately.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Monitoring - Assessing progress and stepping in to make improvements.
Exceptional
Exceeds Requirements
Meets Requirements
Marginal
Needs Work
Other: List special skills or talents
Ability to Recover from Past Struggles
List specific times and instances when the parent has been able to
Child’s Mental Health Diagnosis
Managing multiple needs of family members
Issues with Systems in seeking services on behalf of son/daughter
Working Through Differences with Others
Other: Please list
Use the Space Below to Identify Common Strengths
Life Balance Wheel
Life Balance Wheel Here is a tool you can use to assess the level of your satisfaction with all of the aspects of your life. Rate your satisfaction with each aspect, using a scale from zero to ten, with ten being very satisfied and zero being completely unsatisfied.
Self Care
Work
Intimate Partner/Family
Friends/Social Life
Financial Aspects
Health & Wellness/Body Image
Spiritual Aspects
Community/Service
Emotional
0%
25%
50%
100%
Safety
0%
25%
50%
100%
Family
0%
25%
50%
100%
A Place To Live
0%
25%
50%
100%
Cultural/Spiritual
0%
25%
50%
100%
Legal
0%
25%
50%
100%
Health
0%
25%
50%
100%
Social/Fun
0%
25%
50%
100%
School/Work
0%
25%
50%
100%
Other
0%
25%
50%
100%
Name
This field is for validation purposes and should be left unchanged.
This iframe contains the logic required to handle Ajax powered Gravity Forms.
Page load link
Go to Top
