ࡱ>  @ :bjbj5*5* ""W@W@D[(hhht6(,i@mVmVmVm1npT rÇ$$FR r1n1nrr VmVmԊuuurVmVmÇurÇuuuVm hrjuw0u87s8u((8urrurrrrr ((@,Odu((,ORELATIVE CAREGIVER HOME STUDY OUTLINECase :# FORMTEXT      Case Name: FORMTEXT        FORMTEXT      Worker Load #: FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT   Michigan Department of Human ServicesWorker Name: FORMTEXT      POS Agency: FORMTEXT      Date Child Entered Care: FORMTEXT      Children s Name and Ages(s): FORMTEXT      1.Name of Caregiver(s): FORMTEXT      Address: FORMTEXT      Phone Number: FORMTEXT      2.Household Members (HHM):NAME:DOBSS#*RELATIONSHIP TO CHILDID CONFIRMED  MACROBUTTON [1] "Click Here and Type"  Describe the family connection which make up the relation.  MACROBUTTON AcceptAllChangesInDoc  MACROBUTTON [1] "Click Here and Type"  MACROBUTTON[1]"Click HERE and Type"  MACROBUTTON[1]"Click HERE and Type"  * Social Security Numbers must be redacted from all written reports (see policy CFF 722-3) 3.Dates of contact with household members, including on-site visit:DATETYPE OF CONTACT  MACROBUTTON [1] "Click Here and Type"  MACROBUTTON [1] "Click Here and Type"  4.Date Home Study Completed: FORMTEXT      5.Date of Criminal History Check: FORMTEXT      Results of Criminal History Check: FORMTEXT       FORMCHECKBOX N/A: No Criminal Historya.If there is a criminal history, is the conviction for child abuse/neglect, spousal abuse, a crime against children (including pornography) or crime involving violence, rape, sexual assault or homicide but not including other physical assaults or battery? FORMCHECKBOX Yes:Placement is prohibited; Document reason and rationale for denying the placement. FORMCHECKBOX No:List all other offenses. Describe the length of time since the offense, any services completed that rectified the situation, and any threatened risk of injury or harm to the child placement.  MACROBUTTON [1] "Click Here and Type"  b.Address any risk factors that might impact the safety of the child and describe what protective interventions are in place currently. FORMTEXT      6.Date of Central Registry Check: FORMTEXT      Results of Central Registry Check: FORMTEXT      a.If there is a history of abuse or neglect, describe the length of time since the substantiation and any services that have been provided to rectify the problem(s). FORMTEXT      b.Address any risk factors that might impact the safety of the child and describe what protective interventions are in place currently. FORMTEXT      7.Date discussion held with relative regarding licensure: FORMTEXT       FORMCHECKBOX Relative is interested in pursuing licensure. The relative has been referred to a certification worker. FORMCHECKBOX Relative is not interested in pursuing licensure and a waiver has been signed.8.Caregiver(s) Relationship Status:Is the caregiver involved in a relationship? FORMTEXT      Describe the relationship?(Describe strengths of the relationship & areas need in work or attention. Describe how the couple handles stress, decision making etc.) FORMTEXT      Is that person living in the home? FORMTEXT      Have there been any incidents of domestic violence in the relationship? FORMTEXT      Is there a history of domestic violence for the caregiver or any other household member? Describe. FORMTEXT      9.Substance Abuse:Does the caregiver or any HHM have a substance abuse or alcohol problem? FORMTEXT      Is there a history of substance abuse or alcohol problems or treatment for any household member? FORMTEXT      10.Mental Health:Describe and evaluate the current mental and emotional health of the caregiver(s) and household members. Is there a history of mental health problems or treatment for the caregiver or any household member including marriage counseling for the children? Include current prescriptions for psychotropic medications. FORMTEXT      11.Physical Health:Describe the caretaker(s) physical health. If physical health condition is noted, describe how condition would affect the care of the child(ren) in the home. FORMTEXT      12.Financial/Employment Status:List all sources of income for the household. Are they adequate to meet the needs of the placement? 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FORMTEXT      13.Day Care and Supervision:Discuss the caregiver(s) plans for day care if necessary. FORMTEXT      What arrangements would be made for alternative care for the child if the caregiver is unavailable? FORMTEXT      14.Sleeping Arrangements:Describe and view the sleeping arrangements for the child. FORMTEXT      15.Motivation for placement of the child(ren): Attitude of each member of the household toward accepting the child(ren). Attitudes towards the birth parent(s). FORMTEXT      16.The capacity for and willingness to support the case plan for the child(ren) in their care: Discuss the family s capacity and willingness to cooperate with the supervising agency, the school system, child s therapist, the parenting time plan outlined in the treatment plan, etc. Address the caregiver s ability to protect the child(ren) from further harm. FORMTEXT      17.Family s willingness to work with the child s birth family: Does the family agree that they will not allow the child(ren) s parent(s) to live in their home without the agency s approval? Do they agree to not release the child to anyone, including birth parents, without the supervising agency s approval? FORMTEXT      18.Family methods of behavior management and discipline of children: Is the family willing to follow the supervising agency s discipline policy? Discuss family s method of behavior management.  FORMTEXT      19.Discuss the family s capacity for parenting relative to the child(ren) s age and developmental needs. Describe their capacity and disposition to give the child guidance, love, and affection. FORMTEXT      20.Is the caregiver committed to provide a stable living environment for the duration of placement? Describe the caregiver s ability to provide permanence if necessary. FORMTEXT      21.Conclusion: Based on information gathered summarize the family s functioning as it applies to their capacity to care for the child(ren). FORMTEXT      22.Recommendation: Placement with caregiver is Approved/Denied. If the relative is pursuing licensure, indicate if licensure would be recommended & explain what is needed to complete the licensing process.  FORMTEXT      Foster Care Worker s Signature:Date:Foster Care Supervisor s Signature:Date:Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.cc:Case FileCourtParent(s)  See policy. Redact Central Registry and LEIN information.Relative DHS-197 (Rev. 3-09) Previous edition obsolete. 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