CHILD WELFARE PLACEMENT ASSISTANCE REQUEST
Michigan Department of Health and Human Services
Child/Youth Name	MiSACWIS Person ID	Date of Request
Requester Name	Email	Telephone
Primary Specialist Name	Email	Telephone
Child/Youth Gender	Gender Identity	DOB	County	PAFC
Female Male	Female Male
Race	Hispanic
African American	Caucasian	Asian	Yes No
Native American	Bi-Racial	Other
Legal Status	Is the Court in Agreement with the Placement?
40-Court Ward Delinquent	90-Temp Court Ward 42 and Delinquent Ward 40
Yes No
41-PCW	91-Perm Court Ward 41 and Delinquent Ward 40
42-TCW Neglect	92-Temp Court Ward 42 and Act 150/46
44-MCI	93-Perm Court Ward 41 and Act 150/46
46-State Ward Delinquent	94-MCI Ward 44 & Delinquent Court Ward 40
52-MCI Ward/44 and Act 150/46
Permanency Planning Goal
Adoption	Placement with a fit and willing Relative
APPLA	Reunification
Guardianship
Type of placement request
Non-Secure Residential	Secure Residential	Shelter
Treatment Foster Home	General Foster Home	Adult Foster Care Home
Reasons for placement disruption, triggers
Barrier to locating placement
Placement History	List residential placement/s
Number of Foster Homes
Number of Psychiatric Hospitals
Number of Residentials
Number of Relative Placements
Number of Shelter Placements
Last date of Shelter Placement
Name of Current Placement	30 Day Notice	Date Received
Yes No
Has an FTM been held?	Has a 987 been Completed?
Yes No	Yes No
Current service providers (check all that apply)
Therapy	Medication Reviews	CMH	Trauma Assessment
Wraparound	SED Waiver	Other
Current Diagnosis	Medications
IQ score, if known	Doc Level
Special and/or Medical Needs
Child's needs to support next placement (check all that apply)
Inappropriate Sexual Behavior	Physical Aggression	Truancy
Suicidal Ideations/Attempts	AWOL	Mental Health Needs
Cognitive Limitations	SOGIE Supports	Peer Relations
Self-Harm	Developmental Needs
Placement Outcome	Date
Efforts to Place, Including Dates/Results (use additional pages if needed)
Name of Program	Date of Contact	Reason for Rejection or Waitlist Timeframe
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.