ࡱ> y Ybjbj .{{rN<``"""""'''X}~L'cD.03,3,3,345c6`W`&a&a&a&a&a&a$)fhJaU"84488Ja"",3,3cvCvCvC8R",3",3W`vC8W`vCvCaU MX,3Pi`8mW:C`c0cWiz:itMXi"[X606"vC717666JaJaV> 666c8888i666666666` !: CHILDREN S FOSTER CAREDHS FC Worker Load #: FORMTEXT      INITIAL SERVICE PLANDHS FC Worker Name: FORMTEXT      Michigan Department of Human ServicesPAFC Agency Name: FORMTEXT      PAFC Agency Worker Name: FORMTEXT      County of Referral: FORMTEXT      Court Jurisdiction: FORMTEXT      Court Docket #: FORMTEXT      Date Completed: FORMTEXT      Report Date: FORMTEXT      Report Period Begin Date: FORMTEXT      End Date: FORMTEXT      IDENTIFYING INFORMATIONChild(ren): (List separately) name, date of birth, case number, date entered care, current placement type (if relative care, name and address of relative; if institution, name and address of institution; if foster home, note foster home placement only), date entered current placement, and permanency planning goal. Specify if the child(ren) is Native American and tribal affiliation, if applicable.  MACROBUTTON [1] Add Child(ren) Below  To insert additional names, copy and paste below Native American row.NameDate of BirthLog NumberCase NumberChild GenderChild RaceHeightWeightHair ColorEye ColorReligionDated Entered CareDate of Current PlacementCurrent Placement TypeAnticipated Next PlacementDate of Anticipated Next PlacementCurrent Legal StatusFederal Permanency Plan GoalChilds Address (if not FH)Native American?If Yes, Tribal AffiliationInsert copied rows here Document in social work contacts date Native American question asked, to whom, and outcome. Parent (Caretaker) Name(s): Name and relationship to child, date of birth, address/phone (if multiple children are included in this service plan, the names of each mother and father should be listed; name of father or mother should be listed even if whereabouts are unknown). Include any non-parent adults involved in the household that the court may order to participate in the service plan or who will be involved in the service planning. A household contains biological or legal parents. If there is a step-parent that person must be in the household. These households must be designated as participating or non-participating. Indicate Yes or No if the parent is participating in service planning, cant locate/unavailable, deceased, signed APPLA/APPLA-E agreement in place, parental rights terminated, refused, reunification services not need/per count order, or unwilling. Definitions: Cant locate / Unavailable Worker has completed a diligent search for parent(s) with legal right to the child(ren) through such things as Secretary of State inquiry, search of telephone books, US Post Office address search, follow up on leads provided by friends and relatives, legal publication, etc. and has been unable to locate. The parent(s) has refused to respond to mailings from the worker. If there is no legal father, attempts should be made by the worker to identify and locate the putative father in order to establish paternity. (See FOM 722-6, Efforts to Identify and Locate Absent/Putative Parent(s) for more information.) Deceased Is used when the parent is deceased. Not an Assessment Household There is no legal, biological, or putative parent in the household. Another Planned Permanent Living Arrangement (APPLA/APPLA-E) For youth 14 and older with an APPLA Agreement accepted by the court (FOM 722-7) For youth 16 and older with an APPLA-E Agreement accepted by the court (FOM 722-7) Parental Rights Terminated Is used when parental rights have been terminated. Refused The parent has indicated in writing to the court that he/she does not intend to participate in reunification. Reunification Services not Needed/Per Court Order The court has determined that reunification services no longer need to be offered to the parent. Document court determination that reunification services no longer need to be offered in the reasonable efforts section of the service plan. Unwilling Worker has attempted to engage parent(s) with legal rights to the child(ren) in reunification services through scheduled appointments in the office, in the parents residence, or at a location designated by the parent at least once a month in a six month period as documented in the case file.   MACROBUTTON [1] Add additional parents below  To insert additional names, copy and paste rows below Protective Services Risk Level.NameRelationshipChildrenParticipatingParents Current Address:Date of BirthTelephone:Protective Services Risk Level:Insert copied rows here I.LEGAL STATUSThe petition is included in the legal section of the case file and is not repeated in the Legal Status of this file. Summarize the allegations and the disposition in the Reason Child(ren) entered care section of this report.A.Reason child(ren) entered care l Describe the event or incident that led to the removal and placement of the child(ren). l Are there prior CPS referrals, investigations, services and / or placement for this family? If yes, then describe. l If any child(ren) remain in the family home, indicate the reasons why the child(ren) remaining in the home are safe and what services are being provided to ensure continued safety.   MACROBUTTON [1] Click Here and Type  B.Court History Child(ren): (List separately) name, petition date, petition type, hearing date, hearing outcome, order date, order type, requirements of the court through its order.  MACROBUTTON [1] Click Here and Type  C.Next Court Date  MACROBUTTON [1] Click Here and Type  II.Reasonable EffortsNote:For children who may be Indian Children, see NAA 205, Active Efforts. For all other children, see FOM 722-6, Reasonable Efforts. Information from CPS transfer.A.Include services that were provided to the child(ren) and parent(s) to prevent removal.   MACROBUTTON [1] Click Here and Type  B.If services were not provided, were not required or if providing services to the family was not reasonable, explain why.   MACROBUTTON [1] Click Here and Type  C.Likely harm to the child(ren) if he/she were to be separated from parents, guardian, or custodian?   MACROBUTTON [1] Click Here and Type  Likely harm to the child(ren) if he/she were to be returned to parents, guardian, or custodian?   MACROBUTTON [1] Click Here and Type  III.Social Work Contacts l List date, person(s) contacted, role/position, type of contact (telephone, in person, home visit, parenting time, worker/supervisor consultation, office visit, etc.) and contact location (foster home, court, school, etc.) for each contact, attempted contact and scheduled but unkept appointment. l Document date Foster Parent/Relative Caregiver provided notice of court hearing. l Provide a brief narrative of topics covered during the contact. Limit the narrative to 2-3 sentences. l See FOM 722-8, Initial Service Plan for required face-to-face contacts and required narrative.   MACROBUTTON [1]  Click Here and Type  IV.Assessment Please complete each section for every household.A.Family Social History and Assessment 1.Family History l Describe the family of origin for all caretakers and non-parent adults who are involved in the case. l Is there a history of child abuse or neglect and/or placement for the caretaker(s)? l How does the caretaker s history impact his or her own parenting skills and the current situation? l Describe other relevant information about the adult members of the household, including any significant health issues, criminal history, intra-familial relationships. l Briefly summarize the adult (s) interaction with child(ren) and with each other, if applicable. l Describe the willingness and capacity of the adult(s) to change the situation that brought the child(ren) into foster care.   MACROBUTTON [1]  Click Here and Type  2.Family Self Assessment l What is family s reaction to the event / removal and the agency s definition of the problem? l What is the family s definition of the problem? l What is the family s assessment of their functioning? l What does the family think would make things better? l What resources does the family believe will help meet goals?   MACROBUTTON [1]  Click Here and Type  3.Family Resources l Identify the relative network resources currently provided or available potential resources, and the resources from the surrounding community. l Include an assessment of family s feelings of support from the relative network.   MACROBUTTON [1]  Click Here and Type  4.Religious Affiliation (if applicable) l What is the religious affiliation of the parent(s) and child(ren)? l What is the family s history of participation? l What are the participation and attendance requirements? l Explain any special dietary requirements, grooming, dress or make-up requirements for the child(ren) in placement.   MACROBUTTON [1]  Click Here and Type  5.Family Assessment of Needs and Strengths l Address and explain each individual item scored as a need on the Family Assessment of Needs and Strengths for each caretaker and household). Please attach a DHS-146. l Identify the needs that (provide specific and concise examples) are primary barriers to reunification and any substance abuse needs scored. l Indicate how the primary barriers are related to the reasons the child(ren) entered care, and l The priority for treatment services during the ISP planning period. l Address and explain each individual item scored as a strength on the Family Assessment of Needs and Strengths for each caretaker and household); ll List and describe strengths in the family not identified on the assessment but are present in the family. l Describe all other relevant information about the caretakers and non-parent adults, including: ll Observations on intrafamilial relationships and participants in the case, and ll The results of the Central Registry and criminal history checks, if available.   MACROBUTTON [1] Click Here and Type  B.Child Social History and Assessment The foster care worker must request information from the child(ren)s family, foster family, the child (when appropriate) service providers, and any other professionals familiar with the child prior to completing the child(ren)s needs and strengths assessment and social history. 1.Placements during the report period.l Describe, for each child(ren) (list separately): name, living arrangement, begin date, end date, reason for replacement, efforts made to prevent a replacement, and describe all prior formal and informal placements.  MACROBUTTON [1]  Click Here and Type  l For Indian children, include Foster Care Placement Preference, NAA 215, Placement Priorities for Indian Children.2.Provision For Medical, Dental and Mental Health Services MEDICAL For each child complete the following: l Child name l Current health status and medical needs at time of entry into foster care. l List prescribed medications and regularly dispensed over-the-counter medications, including dosage, diagnosis resulting in prescribed medications and prescribing physician. l Documentation of informed consent for each psychotropic medication. l Any needed emergency medical, dental and health care provided since entry into foster care. l Date of last full medical examination. l Description of any needed medical follow-up appointments. l Immunization status (refer to immunization chart in FOM 722-6). l Child s perception of their medical needs, if applicable.  MACROBUTTON [1]  Click Here and Type  DENTAL For each child complete the following: l Child name l Date of dental examination or date of scheduled appointment. l Description of any needed dental follow-up appointments. l Child s perception of their dental needs, if applicable.  MACROBUTTON [1]  Click Here and Type  MENTAL HEALTH For each child complete the following: l Child name l Date of referral to mental health provider for mental health screening and/or assessment. (From the 30 day medical/physical exam.) l Description of any needed mental health treatment/assessment, if applicable. Include name of treatment provider, frequency of sessions and treatment goals. l Child s perception of their mental health needs, if applicable.  MACROBUTTON [1]  Click Here and Type  3.Child History and Current StatusDescribe, for each child under court jurisdiction: l A physical description including distinctive characteristics. l Emotional and physical development. l Past experiences, and problems. l Participation in extracurricular/cultural/hobbies, likes and dislikes, etc. l Relationships with siblings, if applicable. l How the child s permanency plan was shared with the child and the child s feelings about the plan.   MACROBUTTON [1]  Click Here and Type  4.Education Information For each child, complete the following information: l Child name. l Statement documenting child/youth is attending elementary or secondary school as a full-time student, has completed secondary education or is incapable of attending school on a full-time basis due to a medical condition. l Name of the school child was attending at time of removal. l Grade. l Special education information, if applicable. l Determination of preferred school for child based on best interest factors and input from parent(s) or legal guardian and educational liaison. (See FOM 722-6) l School transportation plan (include role of the school and foster parent, if applicable). l Date child began attending school (after removal). Full-time attendance is required within 5 days of placement. If child did not start school with five days, give explanation. l Verification from new school that the child s previous school record has been obtained with 30 days (if child changed schools). l Assessment of child s educational needs (from CANS, based on educational assessments, information obtained from parents, teachers, foster parents, child/youth and/or educational liaison). l Description of provided services from school, parent, foster parent and others to meet the child s educational needs.   MACROBUTTON [1]  Click Here and Type  5.Child(ren) s Reaction to PlacementDescribe, for each child under court jurisdiction, their reaction to: l the abuse and/or neglect that led to placement, l the placement out of the family home. (Separate from the family reaction), and l the services the child feels would benefit his/her family. l Child s feelings and observations about current placement.   MACROBUTTON [1]  Click Here and Type  6.Child Needs and Strengths AssessmentAddress and explain each individual item scored (with specific and concise examples) as a strength or need on the Child Assessment of Needs and Strengths for the child(ren). Please attach a DHS-432, 433, 434 and/or 435. l Identify and explain the priority needs of the child(ren) for service. l List and describe all strengths of the child whether identified on the assessment or not. l Identify the situational concerns, which cannot be identified in consecutive report periods. l If age appropriate, specify child s perception of needs and strengths.  MACROBUTTON [1]  Click Here and Type   MACROBUTTON [1]  Add additional child(ren) below To insert additional child(ren), copy and paste below 7.a.7.Placement Informationa.Placement Selection Criteria Child Name:  FORMTEXT      Rank each from 1  4; 1 being the reason(s) most important to the placement decision, 3 the least important and 4 not applicable.The case plan which includes the goal of permanence.The physical, emotional, educational and safety needs of the child(ren).Proximity to the child(ren)s family.Placement within relative family network of the child(ren).Placement with siblings of the child(ren).The child(ren)s and child(ren)s familys religious preference.The least restrictive, i.e., most family like setting.The continuity of relationships.Availability of placement resources for the purposes of timely placements.Expressed preferences for placement by the foster child.Appropriateness of the childs current educational setting and the proximity to the school child is enrolled at time of removal.Insert copied rows here b.If any Placement Selection Criteria are not met, explain why not.  MACROBUTTON [1] Click Here and Type  c.For Indian Children, include the Foster Care Placement Preference from NAA 215, Placement Priorities For Indian Children.  MACROBUTTON [1]  Click Here and Type  8.Placement Resources a.Sibling Placementl If a child has siblings and who are not placed in the same placement, describe efforts to place siblings together and provide an explanation of the reasons for the split placement. l Describe the ongoing efforts to place the siblings within the same home. l Note: If siblings are split, second line supervisory approval is required. The second line supervisor must sign the ISP in the Signature Section. l If there are no siblings or if siblings are placed together, write N/A.   MACROBUTTON [1]  Click Here and Type  b.Sibling and Relative VisitationVisits between siblings are to occur at least monthly, if in separate placements. Specifically document the following: l Dates of visits or contacts. l Location of visits or contacts. l Duration of visits or contacts. l Other ongoing interactions between siblings (phone calls, letters, school activities, etc). l Worker assessment on the quality of sibling visitation, based on personal observations, each child s description of visits and any reports from others, including parent(s), relative(s) and foster parent (as applicable) l Include a discussion of any exceptions (missed appointments, changed appointments, suspension of appointments and changes in supervision status) to the plan during the reporting period. l Discuss any visitation arrangements for relatives.   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CJOJQJphftttt"u$u&u(uJutuvuxu|uuuuuuuuuuuvnvȻ~p~\H\'hh]5<B* CJOJQJphf'hh5<B* CJOJQJphfhlh{|5CJOJQJh~5CJOJQJhlh55CJOJQJhlhHB*ph hlhHjhlhHU hlh5hlh5CJOJQJ$hyh5<B* CJOJQJphf(h]Uh7c<B* CJ OJQJaJ phfh7c<B* CJOJQJphf"u$u&uzu|u~uuuu{{ $$Ifa$$If$a$  ]^ ]^[kd2$$IflFT *@     4 laytuuuuvvw@w~wwww:xx@xyyyyl{n{p{r{{{{{{|,.046ลylhlhqCJOJQJhlhqB*phUjhlhqU hlhqhlh5CJOJQJ$hyh5<B* CJOJQJphf$hyh8D<B* CJOJQJphf(h]Uh7c<B* CJ OJQJaJ phfh7c<B* CJOJQJphfh<B* CJOJQJphf){{{2468|ss $Ifgd fn$a$gdq  ]^ gdq ]^gdq`kd3$$IflFV *@     4 laytq  Click Here and Type  Sibling placement/visitation is contrary to the children s safety or wellbeing due to:.  FORMCHECKBOX N/A children placed together FORMCHECKBOX The visit may be harmful to one or more of the siblings FORMCHECKBOX The sibling is placed out of state in compliance with the Interstate Compact on Placement of Children.  FORMCHECKBOX The distance between the children s placement is more than 50 miles and the child is placed with a relative. FORMCHECKBOX One of the siblings is above the age 16 and refuses such visits, including reasons for refusal. FORMCHECKBOX Other. (If other, provide explanation in summary below.)  MACROBUTTON [1]  Click Here and Type  c.Relative Notification, Resources and Placementl Identify any relative resources (in Michigan and other states per Interstate Compact for Placement of Children  ICPC - procedures) with the potential to provide placement for the child, including relatives identified by the parent and child or other supports as indicated by the DHS-989, Relative Response. l Describe the efforts that have been made to place the child(ren) with family or within the kinship network. l If a decision has been made regarding relative care placement of the child, include the decision and the rationale for the decision or attach a copy of the DHS-31, Foster Care Placement Decision Notice. l Attach any completed home studies to this ISP.   MACROBUTTON [1]  Click Here and Type  d.Best Interests of Current Placementl Describe the foster parent / relative / unrelated caregiver s willingness and capacity to meet the specified needs of the child. l Describe why the current placement is in the child s best interest. l Describe how this specific placement supports the child s permanency plan. l Document any CPS complaints regarding the caregiver omitting any information about the CPS referral source. l Document any foster home licensing complaint investigations regarding caregiver during this report period and any corrective action plans that were a result of the complaint. l Describe any safety concerns in the home and specify how it will be addressed.   MACROBUTTON [1]  Click Here and Type  9.Residential CareDescribe reasons for residential placement. Identify the plan for services that will allow the youth to be placed in a less restrictive setting. l If the youth is 10 years of age or over and is placed in a residential or institutional setting, the worker must document if Wraparound, assisted care, date of PPC and/or other efforts were made to prevent the residential placement. l If the child under age 10 is placed in a residential or institutional setting, the worker must document the Wraparound, assisted care, date of PPC and/or other efforts made to prevent the residential placement. Document completion of the screening for Fetal Alcohol Syndrome (FAS). If there were no services provided, explain why not. If the youth is not placed in a residential or institutional setting, write N/A in the space provided.  MACROBUTTON [1]  Click Here and Type  C.Foster Parent/Relative Caregiver Input l Attach written input from the caregiver(s) about the child(ren). If a written statement is not available, summarize the caregiver(s) feedback. l Document date Medicaid card, Medicaid number and Consent for Emergency Treatment card (DHS-3762) given to caregiver. l Describe the caregiver family s adjustment to the child s placement. l Document how the permanency plan for the child was shared with the caregiver and the caregiver s comments regarding the permanency plan. l Document how the caregiver involves the parents in decision making regarding the child(ren) s needs and activities.   MACROBUTTON [1]  Click Here and Type  D.Progress to Date l Identify any changes in the family since the child(ren) entered care. (Provide specific and concise examples.) l Record all referrals made for the family since placement including any services provided by the Agency at the time of placement in the Service Referral Table of the Parent-Agency Treatment Plan and Service Agreement. l Provide a narrative of all PCCs held this report period including the outcomes for each meeting. l Specify efforts to identify and locate absent parents.   MACROBUTTON [1]  Click Here and Type  *Please see the attached Parent-Agency Treatment Plan and Service Agreement. V.Recommendation to Court (Complete for each child) A.Should Child(ren) Remain in Out of Home Placement? l For each child under court jurisdiction, for the period covered by this report, identify case action as continued placement, return home and monitoring, or closure. l If the child(ren) should remain in out-of-home placement, describe why it is not in the child(ren) s best interest to be returned home, placed for adoption, or placed within the relative network.   MACROBUTTON [1]  Click Here and Type  B.Mandatory Petition for Termination of Parental RightsIf a mandatory petition for termination of parental rights has been filed requesting termination of parental rights at the dispositional hearing, the recommendations should contain either:1.A statement that the agency believes it is in the child(ren) s best interest to terminate the parents rights to the child(ren) and the reasons why; or2.Documentation regarding the compelling reasons why termination of parental rights is not in the child(ren) s best interest.If the Mandatory Petition section is the same for all children, check yes and the appropriate recommendation below. If this section is different for one or more children in the family, check no. Then click in the Child Name section and follow directions to add a section for each child for which the recommendation is different.This recommendation applies to all children: FORMCHECKBOX Yes FORMCHECKBOX No  MACROBUTTON [1]  Add additional Recommendations below  To insert additional Recommendations, copy all rows (including  Click Here and Type section) and paste below. Place an X after a through g if appropriate.Recommendation for: FORMTEXT       Enter the child s name.Place an X in only one box (1  3) and as many a  I as necessary if X is placed in 3.1.A mandatory petition is not required. If #1 is checked, a petition for termination for parental rights has not been filed. Write N/A in the space below.2.A petition for termination of parental rights has been filed and it is in the child(rens) best interest to proceed. If #2 has been checked and it is in the best interests of the child to proceed, provide the reasons why in the space below. 3.A petition for termination of parental rights has been filed and it is not in the child(rens) best interest to proceed. Indicate why termination is not in the best interests of the child by checking as many boxes as apply below:a.Adoption is not an appropriate permanency plan.b.The child is being cared for by a relative.c.No grounds to file a termination petition exists.d.There are international legal obligations or compelling foreign policy reasons that preclude termination of parental rights.e.The supervising agency has not yet provided the services detailed in the prior service plans to make reunification possible.f.Child is an unaccompanied refugee minor.g.Other. Explain below. If this is the compelling reason, there must be clear documentation within the case service plan of the individual circumstances of the child that necessitates this selection.  MACROBUTTON [1]  Click Here and Type  Insert copied rows here C.Recommended Court Orders In this section, write any court orders requested for parental or caretaker compliance with the service plan. If applicable, request that non-parent adults participate and comply with the service plan.   MACROBUTTON [1]  Click Here and Type  Report Date: REF Date2  Report Period Begin Date: REF BeginDate  End Date: REF EndDate  By signing below on behalf of the Department of Human Services, we agree to those activities outlined above and will assist the family in their efforts to facilitate the Permanency Planning goal. Split Sibling Placements require approval signature of a second line supervisor.  Name and Title: FORMTEXT       Signature: Date:  FORMTEXT       Name and Title: FORMTEXT       Signature: Date:  FORMTEXT       Name and Title: FORMTEXT       Signature: Date:  FORMTEXT       Name and Title: FORMTEXT       Signature: Date:  FORMTEXT       DHS Local Office Name: FORMTEXT        DHS Local Office Approval: Name and Title: FORMTEXT       Signature: Date:  FORMTEXT      Distribution of Case Plan  MACROBUTTON [2]  Click Here and Type  The local office shall approve, or disapprove, in writing, the ISP for a child in purchased foster care or residential care. The Placement Agency Foster Care (PAFC) Contractor is responsible for all elements of the service plan where they have accepted responsibility for providing family services per the DHS-3600 (RFF-3600) contract. The local office is responsible for reporting requirements only when the POS agency has not accepted total case responsibility. The report from the local office should not duplicate the PAFC Contractor report, but should address those areas for which the PAFC Contractor is not responsible per the DHS-3600 contract. Signing the ISP submitted by the PAFC Contractor indicates approval. The approved ISP is to be returned to the PAFC Contractor within seven days of receipt; a copy is retained in the child s case record. The local office is responsible for knowing what services are being purchased from the PAFC Contractor and for monitoring compliance with the DHS-3600. When a noncompliance situation is identified, it is to be brought to the attention of the PAFC Contractor both verbally and in writing. If efforts to resolve the area of conflict locally are not successful, the situation is to be brought to the attention of the appropriate Urban/Field Office. If Urban/Field Office is unable to intervene successfully, then Child Welfare Contract Compliance Unit is to be involved. (See FOM 914, Monitoring Worker Responsibilities for more information.) Use this field to indicate who typed the report, the date typed, etc., as necessary.  FORMTEXT       Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, 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.AUTHORITY: P.A. 280 of 1939. RESPONSE: Voluntary. PENALTY: None     DHS-65 (Rev. 9-11) Previous edition obsolete. 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