mdhhs-6060, closing prevention plan

Michigan Department of Health and Human Services (MDHHS)

(Revised 9-24)

section 1 – family demographic information

Case Name	Ongoing MiSACWIS Case ID	Court Case Number (if applicable)

Referring County	Program	Phone Number

Family Address	City	State	Zip Code

Referring Worker	Referring Supervisor	Referring Agency

Ongoing Worker	Ongoing Supervisor	Phone Number

Assigned Family Worker	Assigned Team Leader (if applicable)

section 2 – documentation dates

Referral Date	Termination Date	Period cover for report From To

SECTION 3 – RECORD OF CONTACTS DURING THIS REPORT PERIOD DATED

Date and times for face to face	Type (face-to-face, phone, collateral, other)	Names of Person Contacted	Comment (Focus)

Total number of face-to-face visits.

section 4 – case closing prior to initial service plan

Is this being used as a service/term? Yes No

If no, answer N/A and skip to SECTION 5.

If yes, report the following: (Assessment of Family Strengths and Needs, Assessment of Adults in Family and Other Significant People, Child Assessment, Trauma Screening/Assessment, Situation Assessment, Risk Assessment, Routine Inquiry, Safety Plan, Safe Sleep, Infant Plan of Safe Care, Protective Factors Retrospective, Other)

section 5 – legal status and current situation assessment (include information regarding most recent court hearing, outcome, and next court date if applicable)

Include information regarding most recent court hearing, outcome, and next court date if applicable.

Other Pertinent Information/Relevant History (if any)

Section 6 – FAMILY GOALS (SPECIFIC, MEASURABLE, ATTAINABLE, REALISTIC, TIME-LIMITED), ACTION STEPS, AND SERVICES PROVIDED/FAMILY PROGRESS TO DATE

List goal and action steps that each household member and family preservation worker will be responsible for, progress on action steps, and participation in intervention. Include protective factors in progress to date.

Section 7 – SPECIFIC ASSISTANCE TOTAL AND WHAT WAS PURCHASED

Specific assistance total and what was purchased?

Section 8 – RISK ASSESSMENT UPON CASE CLOSURE, CLOSING SAFETY PLANS, UPDATED INFANT PLAN OF SAFE CARE, TRAUMA SCREENING/SERVICES UPDATE

Should be completed for both caregivers, risk level for both caregivers, and level of engagement with both primary and other caregivers for all risks identified at time of referral and time of written report.

Section 9 – PROTECTIVE FACTORS RETROSPECTIVE AT CLOSURE

Include information from referred parents perspective of their protective factors and should not include specific scores they give themselves.

Section 10 – REASON FOR CLOSURE

Reason for Closure

Section 11 – OTHER PLANS AND SPECIFIC RECOMMENDATIONS DISCUSSED WITH FAMILY AND REFERRING WORKER

Outcome of termination conference with referring worker and family. To include aftercare recommendations and the family’s reception to the recommendations as well as who is responsible for each of the recommendations.

section 12 – signatures

Assigned Family Worker	Assigned Family Worker Signature	Date

Team Leader (if applicable)	Team Leader (if applicable) Signature	Date

Program Supervisor	Program Supervisor Signature	Date

Agency Name	Date

County	Date Sent to Referring Worker

section 13 – family signatures (frp only)

Family Member	Family Member Signature	Date

Family Member	Family Member Signature	Date

Family Member	Family Member Signature	Date

Family Member	Family Member Signature	Date

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.