Kinship Caregiver Environment Assessment

Caregiver Information

Caregiver Name Relationship to Child Address Phone Number

Child(ren) Information

Child Name(s) Age(s) How long has the child been living here?

Physical Environment

Describe the home's general condition Are there adequate sleeping arrangements? Yes No Is the home safe and clean? Yes No Other comments on the physical environment

Caregiver Support

What support systems are available to the caregiver? Are there any concerns about the caregiver’s ability to provide care?

Safety Assessment

Any known hazards in the home? Are there any safety measures or precautions in place?

Additional Notes

Other observations or comments