ࡱ> y ibjbj .{{'DL'L'L'L'L'`'`'`'8xx$`'D.'l-l-l-l-.J.,//@CCCCCC$6FH5CL'./..././5CL'L'l-l-4Cb1b1b1./LL'l-L'l-/@b1.//@b1b1R:<l-0kޭz/;@C0D;fIz/I<<IL'7<././b1./././././5C5Ch0./././D././././I./././././././././ &: ADOPTION REFERRALMichigan Department of Human ServicesTO:Adoption SupervisorDate Received: (by adoption supervisor) FORMTEXT       FORMTEXT      FROM:CFC SpecialistLoad # FORMTEXT       FORMTEXT      CFC SupervisorDate FORMTEXT       FORMTEXT      Child s NameChild Current Living Arrangement: FORMTEXT       FORMCHECKBOX DHS Foster Home FORMCHECKBOX PAFC Home(Complete Below or Attach SWSS Foster Care case Summary FORMCHECKBOX Residential/Institutional CareSWSS Log #:DHS Case #:Date of Birth: FORMCHECKBOX Relative Home FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX Other: FORMTEXT      DescribeFamily working with Placement Agency for licensing purposes? FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, which agency: FORMTEXT      CONCURRENT PLANNINGHas the current provider expressed an interest in adoption? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMCHECKBOX UnclearHas the possibility of adoption been discussed with the current provider? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AAre there any others who have expressed an interest in adopting the child? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AName/Address/Phone Number of interested party: FORMTEXT      PAYMENTSIf the child is placed with an unlicensed relative the FC worker must notify FIS/ES to close any FIP payment for the child, enroll relative provider in Model Payments (DHS 2351), and open State Ward Board & Care model payments in SWSS. MCI wards must not be county funded.CURRENT PLACEMENT - ( Complete Below and Attach SWSS Foster Care Case SummaryCurrent Provider/Caretaker NameTelephone FORMTEXT       FORMTEXT      Street Address City, State, Zip Code FORMTEXT      SIBLINGSIs this child a member of a Sibling Group?  FORMCHECKBOX  Yes*  FORMCHECKBOX  No  FORMCHECKBOX  Unknown *If YES List All (attach additional page if necessary)Sibling NameDOBLiving ArrangementTCWMCIPCWNon Ward FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT  LEGAL ISSUESRehearing ox   " $ & : < > H J     * , . 0 D F H R T ÿÿj hz4Uj"hz4Ujhu|Ujhz4Ujhu|Uh&jh&UjAhu|Ujhsz!Ujhz4Uhz4jhz4U hz4h;VYh;VY5$&r '$Ifgd;VYfkd$$Ifl4,,04 lalf4yt4Z5 *$Ifgd;VYrtvx(fkd$$Ifl4p,,04 lalf4yt4Z5 G$IfgdKGfkd$$Ifl4,,04 lalf4yt4Z5x G$IfgdKGfkd$$Ifl4,,04 lalf4yt4Z5 !$Ifgdz4$ L || E$Ifgdsz!ykd$$$Ifl40O,OZ04 lalf4yt4Z5L N Z | !$Ifgdz4ykd$$Ifl40O,OZ04 lalf4yt4Z5Z \ z G$IfgdKGfkdP$$Ifl4,,04 lalf4yt4Z5 || E$Ifgdsz!ykd$$Ifl40,04 lalf4yt4Z5  || G$IfgdKGykd`$$Ifl40,04 lalf4yt4Z5  . 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FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Unknown  FORMCHECKBOX  Other pending legal issue?NEXT COURT DATE: FORMTEXT      Name of Judge/Referee: FORMTEXT      ATTACHMENTS FORMCHECKBOX ISP, last two USPs, all PWSPs FORMCHECKBOX Immunization record FORMCHECKBOX All Early On/developmental assessments FORMCHECKBOX Original Birth Certificate FORMCHECKBOX Verification of Social Security Number FORMCHECKBOX Child s placement history FORMCHECKBOX Current payment authorization FORMCHECKBOX Copies of all court orders FORMCHECKBOX MCI Commitment Order FORMCHECKBOX Initial funding determination FORMCHECKBOX Death certificate of parent(s) (if applicable) FORMCHECKBOX Genogram FORMCHECKBOX All physical/dental/medical records, including medical passport FORMCHECKBOX All psychological/psychiatric records for child/parent FORMCHECKBOX All IEPC reports/special education certifications FORMCHECKBOX Copy of current (within six months) DOC, plus supporting documentation FORMCHECKBOX All court petitions for the case (initial, amended, and supplemental) FORMCHECKBOX Copies of DHS-987, 988, 989 and Initial Relative Placement Home Study FORMCHECKBOX Pictures of child and other family members FORMCHECKBOX CPS complaints, records or documents FORMCHECKBOX Copy of BCAL-3130, Initial Foster Home/Adoptive Evaluation (if applicable) FORMCHECKBOX Foster home licensing investigation reports and any resulting corrective action plans FORMCHECKBOX Denied FORMCHECKBOX Additional Information Needed: FORMTEXT      Date Returned: FORMTEXT       FORMCHECKBOX AcceptedAssigned to: FORMTEXT      Agency: FORMTEXT      Adoption Supervisor SignatureDate Assigned: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. 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