MDHHS-6175, Family Preservation Follow-Up-Attempt Log

Michigan Department of Health and Human Services (MDHHS)

Children's Services Agency

(Revised 3-25)

Case Number

Section 1 – family information

Family Name	Family Phone Number

Family Street Address	City	State	Zip Code

MiFT Worker	Referring Worker	Referring Worker Phone Number

Referral Date	Closing Date	Follow-Up Month 3 Months 6 Months

Section 2 – follow up Attempts

Follow up attempt 1

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Describe sustained goal achievement, case closure safety planning, and/or if family needed additional support to maintain children in the home safely.

follow up Attempt 2

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Describe sustained goal achievement, case closure safety planning, and/or if family needed additional support to maintain children in the home safely.

follow up Attempt 3

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Describe sustained goal achievement, case closure safety planning, and/or if family needed additional support to maintain children in the home safely.

follow up Attempt 4

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Describe sustained goal achievement, case closure safety planning, and/or if family needed additional support to maintain children in the home safely.

follow up Attempt 5

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Describe sustained goal achievement, case closure safety planning, and/or if family needed additional support to maintain children in the home safely.

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.