ࡱ> hkgn @ *JDbjbjʚʚ t  ZZZZZZZ$$$8c\nc240%,',',','((T(,0w1w1w1w1w1w1$N3R519Zh*((h*h*1ZZ,','1R,R,R,h*Z,'Z,'0R,h*0R,R,ZZR,,'2d `Fg\$~*R,<-102R,R6*R6R,nZZZZR6Z`,)0I)"R,k)))))11TB,TTREATMENT FOSTER CARE REFERRAL ACCEPTANCEMichigan Department of Human ServicesI. Child InformationName:Date of Birth: FORMTEXT       FORMTEXT      SWSS Log Number:Case Number: FORMTEXT       FORMTEXT      Date TFC Provider received referral form:Court Number: FORMTEXT       FORMTEXT      County DHS Name:DHS Monitor (if applicable): FORMTEXT       FORMTEXT      II. Treatment Foster Care (TFC) Agency-NameAgency Name:Agency Phone: FORMTEXT       FORMTEXT      FORMTEXT      Treatment Foster Home:Treatment Foster Parent Name(s):Placement Date: FORMTEXT       FORMTEXT      Treatment Foster Home Address:Phone Number: FORMTEXT       FORMTEXT      FORMTEXT      Treatment Team:TFC Supervisor:TFC Supervisor: FORMTEXT       FORMTEXT      Behavioral Aide:Therapist (if identified): FORMTEXT       FORMTEXT      TFC Foster Parent(s):DHS Worker: FORMTEXT       FORMTEXT      Birth Parent(s) or other identified Permanent Caregiver(s):Other: (i.e., LGAL, School etc.) FORMTEXT       FORMTEXT      TFC Worker Assigned:Date: FORMTEXT       FORMTEXT      TFC Supervisor:Date: FORMTEXT      *RV   " $ & : < > H J 0 P R f h j t v x z ոѭո|jZh gUhz5jh gUjvh gUh gjh gUjh~UjhUmHnHujh~Uh~jh~Uhnh:ZK5hnhH5 h:ZKh:ZKhHhh:ZK0TV+sj $Ifgdn<kd^$$Ifl4y,y,y,4 lalf4 $Ifgd:ZK<kd$$Ifl4Py,y,y,4 lalf4 $Ifgd:ZKDHDBm$ L bNNd$$If^gdOkd"$$Ifl40y,y,4 lalf4dL$Ifgd<kd$$Ifl4y,y,y,4 lalf4L N p OFF $Ifgd gOkd$$Ifl40<y,<=y,4 lalf4dL$IfgdOkd~$$Ifl40y,y,4 lalf4 2 N P x OFF $Ifgd gOkd$$Ifl40<y,<=y,4 lalf4dL$IfgdOkdb$$Ifl40<y,<=y,4 lalf4z     $ & ( * > @ B L N R   " $ & , . 0 2 F H J ۘ~ۘsjn hz5Uj hz5Uj hz5Uhz5jhz5Uh ghz5OJQJaJhz5OJQJaJhnh g5\jh gUj2h gUh~jhUmHnHujh gUjh gUh g- ( P OFF $Ifgd gOkd$$Ifl40<y,<=y,4 lalf4dL$IfgdOkd:$$Ifl40<y,<=y,4 lalf4P R +v:iUUdL$If^gdz5<kd$$Ifl4Py,y,y,4 lalf4 $IfgdnOkd$$Ifl40<y,<=y,4 lalf4 X Z !!KB+v: $IfgdnOkd $$Ifl40y,y,4 lalf4d$$If^gdz5Okd $$Ifl40y,y,4 lalf4J T V X Z        , . 0 : < @  4TӼӱӤәӎӃ~ h g5jh gUjh gUj,h gUh gh gOJQJaJj h gUjH h gUjh gUhJh ghnh g5\ hz55hz5jhz5UjhUmHnHu/  > ^J!J!d$$If^gdNlOkd $$Ifl40y,y,4 lalf4dL$If^gdNl<kd` $$Ifl4y,y,y,4 lalf4> @ ~ K7!7!d$$If^gdNlOkd $$Ifl40y,y,4 lalf4dL$If^gdNlOkd4 $$Ifl40y,y,4 lalf424Tt+v:i`` $Ifgd g<kd $$Ifl4y,y,y,4 lalf4 $IfgdnOkd$$Ifl40y,y,4 lalf4Trvx"$8:<FHJL`bdnp j0h gUjh gUjLh gUjh gUh~hz5jhh gUjhUmHnHujh gUjh gUh g h gh g7tv VFFdL$If^gd gOkd$$Ifl40<y,<=y,4 lalf4 $Ifgd gOkdv$$Ifl40<y,<=y,4 lalf4 "JrtVFFdL$If^gd gOkd$$Ifl40<y,<=y,4 lalf4 $Ifgd gOkdZ$$Ifl40<y,<=y,4 lalf4  VFFdL$If^gd gOkd$$Ifl40<y,<=y,4 lalf4 $Ifgd gOkd>$$Ifl40<y,<=y,4 lalf4  VXlnpz|~>>>>">$>@@@ݑjBh gUUjh gUj^h gUjh gU h g5jh gUjhUmHnHujh gUjh gUh ghz5OJQJaJh gh gOJQJaJ3VM $IfgdrOkd$$Ifl40<y,<=y,4 lalf4 $Ifgd gOkd"$$Ifl40<y,<=y,4 lalf4HTV~||^&gUU $Ifgd9Okdl$$Ifl40y,y,4 lalf4dL$If^gdNl<kd$$Ifl4y,y,y,4 lalf4&>||K&gBB $IfgdnOkdP$$Ifl40y,y,4 lalf4dL$If^gdNlOkd$$Ifl4P0y,y,4 lalf4 FORMTEXT      *Initial Service and Treatment Plan due within 30 days of placement.*The child shall not be ejected from the program unless the child presents a consistent danger to self or others.Send copies of referral acceptance to:Referring workerDHS MonitorFoster Care Program Office Designee, (517) 241-7047, faxDepartment 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. 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