Child Neglect Assessment Template

General Information

Child's Name Date of Birth Age Assessment Date

Caregiver/Family Information

Caregiver Name(s) Relationship to Child

Living Situation

Current Living Situation

Areas of Assessment

Basic Needs (Food, Shelter, Clothing) Medical/Dental Care Education/School Attendance Supervision/Safety Emotional Support/Neglect

Indicators of Neglect

Risk Factors

Protective Factors

Action Plan / Recommendations

Assessor's Name

Role/Position