ࡱ>  @ ?xbjbj w) ("""""""6>+>+>+8pl#qD6@v+N-d-d-d-?.#//Hx<*?*?*?*?*?*?$ AR]CN?"2?.?.22N?""d-d-?2525252^"d-"d-x<252x<2525""25d-gr n>+F3^256d?0@25C3xC2566""""C"@5/025Q1t1#///N?N?66!$ 566!TREATMENT FOSTER CARE PLACEMENT REQUESTDepartment of Human ServicesCHILD INFORMATIONNameDate of BirthSWSS Log Number FORMTEXT       FORMTEXT       FORMTEXT      Case NumberGenderRace FORMTEXT       FORMTEXT       FORMTEXT      County of PlacementReferring AgencyReferring Worker:Phone: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Child s current address:Phone:Name of child s current foster parent: FORMTEXT       FORMTEXT       FORMTEXT      Name of Identified Planning Family:Address of Identified Planning Family:Phone of Identified Planning Family: FORMTEXT       FORMTEXT       FORMTEXT      Reason for Referral to Treatment Foster Care (TFC) FORMCHECKBOX Youth is being discharged from a psychiatric placement approved and/or financed by CMH. (Attach discharge recommendation) FORMCHECKBOX Youth is stepping down from residential care and integration into community care requires a highly structured placement. (Attach discharge recommendation) FORMCHECKBOX Youth has a recent psychiatric or psychological diagnosis (DSM-IV, Axis 1) and a rating of severe on one of the following domains on the Child Assessment of Needs and Strengths (CANS): Mental Health and Well-Being, Substance Abuse or Sexual Behavior. (Attach copy of diagnosis and CANS) FORMCHECKBOX Child is under age seven with exceptional and intensive mental health and behavioral needs, who has experienced multiple placements, with poor or no response to mental health treatment, and for whom residential placement would be the only alternate option. The child must have a rating of severe on one of the following domains on the Child Assessment of Needs and (CANS): Mental Health and Well-Being, Substance Abuse or Sexual Behavior. (Attach copy of CANS)Summary of youth/child s need for Treatment Foster Care: FORMTEXT      POS Referring Worker:Date: FORMTEXT       FORMTEXT      POS Referring Supervisor Signature:Date:DHS Monitor/Worker Signature:Date:DHS Supervisor Signature:Date:DHS Determination of Eligibility: FORMCHECKBOX Approved-Without this service, multiple placement disruptions or residential placement may occur.  FORMCHECKBOX Denied- Does not meet TFC eligibility requirements. DHS Gatekeeper Signature:Date:For Wayne County Referrals: Send copy of approval to Juvenile Assessment Center (JAC) to initiate the assessment referral.Date Referred to JAC for Assessment: FORMTEXT      Payment Codes:Orchards Children s Services:6358372Service Code 0785Spectrum Children s Services:6358505Service Code 0785Vista Maria6360076Service Code 0788TFC AGENCY ASSIGNED:ProviderNP     $ & ( * > @ B L N P R f h j t v x z øǪßǪÔǪِÅǪzǪjhS*UjVhS*Uh)jhS*UjvhS*Ujh UmHnHujhS*UhS*jhS*Uh!CJOJQJh!h1h15 h15h1h~h~h~5 h~50PR+ssj+^ $Ifgd~<kd^$$Ifl4y,y,4 lalf4 $Ifgd~<kd$$Ifl4y,y,4 lalf4 $Ifgd~xxB+v:yp jp jp j $Ifgd!<kd$$Ifl4y,y,4 lalf4 $$Ifa$gdS*<kd$$Ifl4y,y,4 lalf4 ( P x z 0bkd^$$Ifl4Fy,    4 lalf4 $Ifgd!bkd$$Ifl4Fy,    4 lalf4z $  j j j $Ifgd!bkd$$Ifl4Fy,    4 lalf4 $Ifgd!    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TheSerialDate = Today() + 14_$ TheDate$ = Date$(TheSerialDate)& SetFormResult "DueDate", TheDate$Q^) EditGoTo "CreateDate" : UnlinkFields EditGoTo "GranteefirstName"- ToolsProtectDocument .NoReset = 1, .Type = 2/ ToolsProtectSection .Section = 2, .Protect = 07>d FileClose 2 SelectName = - 1kpoh`(Attribute VB_Name = "MyInfo" Public Sub Main(X) D.nDescription|Enter Personal rma:zProcDataIInvoke _FuncINoi8l..nADim iRet B  User$ATitleAreaCod-PhonYourExtFax|AC Offic $AddressCitByStat Zip ODILSEB;UN WKRBoss|| 'DEFINE DIALOG BOX WordBasic.BeginDialog 582, 300,} G TextBox 109@ A 5@ 18@ I @ey 56 * 83 _[ 105WDi 2A3321A5r 34 _  | 9 7 @ 1$55E [1 Pi 23` 6i`cV3jFAXAC41e lV1@,CO629 *DI7m pV? UN6z4!l1.yVm23n`~64`'Fz7,, c3z#the followin`g infa@bout ys0elf. ", ׂ !:w5f"bC #1z0@8O$351{1A-ST- u5 abm3r13@? gY  ;"C O-DI-T-U,N-@H47224*; supervisor!a 124f6p6iOKButtY48 8pR21 fCanctel3kEndn ҂dlg!u! As Object: Se$t = CurValues. vGET USER INFO FROMI FILE AND@ PUT I NTOzx.t[GetPrivfileS@@ng$](" "'P:qMY.ini"r hl ? pa"4??>? Mpn_1r &.nAC `axU/-Y??>OMA\C$$a&gp Op | DIpp/-UN0 | {p y QaserInfo", "Boss Name`MYINFO.ini") dlgU.Title = WordBasic.[GetPrivateProfileString$]("t| 'DISPLAY DIALOG BOX AND RESPOTO USER INPUT iRet Dialog.p (If 3-1 Then 'OK BUTTON ?WRI@TE NEW3FO6I FILE xSx wYour ?, - -AreaCod|PhonEExtE@FaxACL+@OfficZ|Address0$ L+gCity ? : |StP  z Zo%  CoCity  ! CoStat$c b CoZip  "Supervi8sor<`, Boss! /Titl% b ' Upd. other  FieldsH on& t Macro Rem" SelA}ed$=G$ ("Curre8ntD9'`Serial = Today() + 14$5()lDure",a"GEditGoTo 0"Cre : Unlink'Grante@efirst3"ToolsProtDocum! .No@et`1, .Type@2/ .8= 2 `0 Else#FileClose D c.@- 1$nd #Sub ME(<<< <h ~ X%"  .@Pp &x  (((P X h]@'If document is protected, Unprotect it.GR ! cladd87 B@ilekPerform Spelling/Grammar check.x (0-0  !X:K !( !B@8.  ReProtect the document. ! cladd87 l B@koAttribute VB_Name = "Module1" Sub FormsSpellCheck2() Dim x As wdNo Then  9ZPassword:="c@ladd87E nd If'P(erf ing/Gramma8r clK.Op2tBs.vWi thFalse EachIn JsZx.Range.iof>$;;5AlwaysSuggest :=Tru; Next: 'Re the=&EW, n orese&, o:=wdAllowOnlyAbAAeK*srU~~~~~~~~~h wLTD~ 4O     iQ  ThisDocumentMyInfoTemplateProjectF@C:\Program Files\Common Files\Microsoft Shared\VBA\VBA6\VBE6.DLLVBA ! 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ClientStateD ClientState Uppercase1Enter the Addressee's 2 digit State Abbreviation. 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