ࡱ> 5@ jbjbj22 *XXb?lllllll\\\8 ]|]h_,dddde4i<)l $$RBنilImeeImImنllddBrrrIm"ldldrImrRr-s:x,llqyd_ 4?*\km.y y X0yRm,qylllllqytImImrImImImImImنن+2d*r2PERMANENCY GOAL REVIEWDepartment of Human ServicesThis form must be completed for all reviews of permanency goals. For children with goals of Permanent Placement with a Relative or Another Planned Permanent Living Arrangement, this form must accompany the request for approval of the goal submitted to the Director of Bureau of Child Welfare.Name of Child FORMTEXT      Log ID Number FORMTEXT      I. Review of permanency options and requirementsCurrent Permanency Goal FORMTEXT      Anticipated Permanency Date FORMTEXT      Answer the following questions or indicate if the information is included in the updated services plans for the child.YESNO1.Reunification After 12 Months Does the case services plan:a.Contain an explanation justifying the continuation of the goal? FORMCHECKBOX  FORMCHECKBOX b.Identify the additional services necessary or circumstances that must occur in order to accomplish the goal? FORMCHECKBOX  FORMCHECKBOX 2.Adoptiona.Is there an adoption worker assigned to the case? FORMCHECKBOX  FORMCHECKBOX b.Is there an identified family and a signed commitment to adopt? FORMCHECKBOX  FORMCHECKBOX c.If there is no identified family is there a written individual recruitment plan in place? FORMCHECKBOX  FORMCHECKBOX d.Has termination of parental rights occurred? FORMCHECKBOX  FORMCHECKBOX e.If termination has occurred:Has the Adoption Application been submitted? FORMCHECKBOX  FORMCHECKBOX Has the BCAL-3130 or Family Assessment been completed? FORMCHECKBOX  FORMCHECKBOX Has consent from the MCI office been requested? FORMCHECKBOX  FORMCHECKBOX f.If the youth is 14 or older have they agreed to the adoption? FORMCHECKBOX  FORMCHECKBOX g.If the youth does not agree, provide information on the youths stated reasons and the process of informing the youth of the possible outcomes of their decision: FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      3.Guardianshipa.Is there an identified guardianship placement? FORMCHECKBOX  FORMCHECKBOX b.Is the child currently living with the identified guardian? FORMCHECKBOX  FORMCHECKBOX c.Is the potential guardian a licensed foster parent? FORMCHECKBOX  FORMCHECKBOX d.Is the Guardianship Application completed and submitted? FORMCHECKBOX  FORMCHECKBOX e.Has the child been consulted regarding the guardianship? FORMCHECKBOX  FORMCHECKBOX f.Is the identified guardian requesting guardianship assistance? FORMCHECKBOX  FORMCHECKBOX 4.Placement with a Fit and Willing Relativea.Is there an identified relative placement? FORMCHECKBOX  FORMCHECKBOX b.Is the child currently living with the identified relative? FORMCHECKBOX  FORMCHECKBOX c.Is there a signed agreement in the file? FORMCHECKBOX  FORMCHECKBOX 5.Another Permanent Planned Living Arrangement (APPLA):a.Is the child age 14 or older? FORMCHECKBOX  FORMCHECKBOX b.Is there an identified caregiver? FORMCHECKBOX  FORMCHECKBOX c.Is there a signed agreement in the file? FORMCHECKBOX  FORMCHECKBOX d.Is the child currently living with the identified caregiver? FORMCHECKBOX  FORMCHECKBOX e.Is the child age 16 or older APPLA-E? FORMCHECKBOX  FORMCHECKBOX f.Has a support person been identified and documented in the file? FORMCHECKBOX  FORMCHECKBOX g.Is there an APPLA or APPLA-E agreement signed and in the file? FORMCHECKBOX  FORMCHECKBOX h.Is there a Transitional Plan documented in the file? FORMCHECKBOX  FORMCHECKBOX Name of Child FORMTEXT      Log ID Number FORMTEXT      New Permanency Goal Assigned FORMTEXT      New Anticipated Permanency Date FORMTEXT      II. 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SupervisorDate FORMTEXT       FORMTEXT      Adoption Supervisor (if applicable)Date FORMTEXT       FORMTEXT      Agency Name: 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. DHS-643 (8-09) Previous edition obsolete. 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