Children's Foster Care Relative Placement Home Study
|CHILDREN’S FOSTER CARE |Case # | |
|RELATIVE PLACEMENT HOME STUDY |Case Name | |
|Michigan Department of Health and Human Services |Worker Name | |
| |Worker Title | |
| |Agency Name | |
| |Placement Date | |
| |Home Study Type: Initial Annual |
|DATE HOME STUDY COMPLETED: |
| |
|Child(ren) Names: |DOB: |Legal Relationship to Prospective Caregiver |Person ID: |
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|Caregiver(s) Name: |DOB: |Email Address: |
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|Caregiver(s) Address: |Caregiver(s) Phone: |
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|ADDITIONAL MEMBERS OF THE HOUSEHOLD |
|Name: |DOB: |Relationship to Caregiver: |
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|SOCIAL WORK CONTACTS (Tab through cells to add additional rows)(Date, Location, Persons Interviewed) |
|CLEARANCES |
|Date of criminal history check for everyone 18 years and older: | | |
| |Criminal History Results: |
| | |N/A - No Criminal History |
| | |Criminal history exists for named offense. PLACEMENT IS PROHIBITED if a member of the household has a felony conviction for one of the following crimes:|
| | |Child abuse/neglect. |
| | |Spousal abuse. |
| | |Crime against children (including pornography). |
| | |A crime involving violence, including rape, sexual assault or homicide but not including other physical assault or battery. |
| | |Physical assault or battery within the last five years. |
| | |A drug related offense within the last five years. |
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| | |Criminal History exists but does not prohibit placement. List the adult’s name, all offenses, and date(s) of conviction. Describe the services completed|
| | |that rectified the situation. Address safety risks and identify protective interventions. If criminal history exists, director approval may be required;|
| | |see FOM 722-3B. |
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|Date of Michigan Central Registry Check: | | |
| |Central Registry Results: |
| | |N/A: Not Found |
| | |Yes, there is a history of child abuse or neglect. If central registry history exists, director approval is required; see FOM 722-3B. |
| | |Identify reasons for substantiations, the length of time since the substantiation, and any services that have been provided to rectify the concern. |
| | |Assess the caregiver’s benefit from services provided. What has changed since the substantiation? If presented with a similar circumstance that led to |
| | |the past substantiation, identify if the provider would do anything different. Describe how the provider would handle the situation differently. |
| | | |
| | |Assess and address any risk factors that might impact the safety of the child(ren) and describe what protective interventions are in place currently. |
| | |Identify supports currently in place to assist the family. Identify if the caregiver is pursuing expungement or has requested expungement in the past. |
| | | |
| | |An adult member of the household has resided in other states in the past five years. Include name of household member(s) and state(s) resided. There |
| | |must be a Central Registry clearance from the identified state(s) within 30 calendar days. |
| | | |
|DESCRIPTION OF HOME |
| |Description of home and rooms, noting condition, layout, appearance. (Does the home meet the minimum level of cleanliness necessary to meet the needs of the |
| |child(ren) to be placed? If not, is the relative taking action to address the home’s deficiencies?) |
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| |Explanation of proposed sleeping arrangement for family members and foster children/adoptive children. Include room sizes and beds currently in rooms. |
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| |Description of play space. |
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| |Does the caregiver have pets? Yes No |
| |If yes, does the pet have current vaccinations? |
| |Is the animal licensed if that is required by the municpality where the family lives? |
| |Is the pet friendly or is the pet a safety concern? Explain what makes the pet a safety concern; for example, how the pet interacts with household members, with|
| |strangers who visit the home. |
| | |
| |Are there water hazards on or near the premises? Yes No |
| |If yes, provide an explanation of how the caregiver plans to safeguard children around them. |
| | |
| |Are there smoke detectors on each floor and between each sleeping area and the rest of the home? Yes No |
| |If no, describe the steps the caregiver will take to meet this requirement. |
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| |Is there a carbon monoxide detector installed as recommended by the manufacturer? Yes No |
| |If no, describe the steps the caregiver will take to meet this requirement. |
| | |
| |Are there weapons in the home? Yes No |
| |If yes, specify type (rifle, handgun, bow and arrow, bb gun, etc.), where they are stored (ammunition stored separately), and how they are secured (trigger |
| |locked/inoperable). |
| | |
| |If there are handguns, has the caregiver provided a copy of the required permit? Yes No |
| |If no, describe the steps the caregiver will take to meet this requirement. |
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| |Where are medications stored, if applicable? |
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| |Means of Transportation. Describe the ages and makes of automobiles, including reliability of each vehicle. Verify and indicate if the caregiver has a valid |
| |driver’s license, auto insurance, accessibility to required safety seats for young children, and accessibility to public transportation, if needed. |
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|FINANCIAL AND EMPLOYMENT STATUS |
| |Date family provided the DHS-Pub-457 for children in relative care. |
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| |Describe the family’s financial and employment status, including: |
| |Sources of income. |
| |Stability of income. |
| |Expenses. |
| |Is the family current on their bills? |
| |Assessment of family’s money management skills and ability to meet their needs within their current income. |
| |Can the family meet the financial expenses associated with having a foster/adopted child placed in the home prior to any payments starting? |
| |Does the family have a plan for financial changes that may occur in the future? |
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| |There is adequate income to support the placement. Yes No |
| |If no, explain how the placement will meet the child’s needs. The answer must take into consideration the information obtained from all items within this |
| |section. |
| | |
| |If income is based on disability; e.g., SSI, Social Security Disability, long term disability payments from a job, workmen’s compensation, there must be |
| |verification of the physical or mental disability and an assessment of how that impacts the ability to provide foster/adoptive care or be a member of the |
| |household. |
| | |
| |If child support payments are ordered, are the payments being made and are they current? If there are arrears, how much are they and what is the plan to bring |
| |the payments current? |
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|FAMILY LIFE |
| |Marital and family status and history, including past level of family functioning and relationships and any incidents of domestic violence. For the current |
| |relationship, include: |
| |Brief history, including date and place of marriage, if applicable. |
| |Any history of separations or domestic violence. |
| |Strengths of relationship, areas of work or attention. |
| |Common/shared interests or lack thereof. |
| |Roles, division of labor, decision-making process, handling stress or disagreements. |
| |Assess level of satisfaction, stability. |
| | |
| |Family: |
| | |Activities, goals, values, role of religion, church involvement. |
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| | |Challenges, stressors, any history of help-seeking. |
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| | |Losses and coping mechanisms. |
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| | |Expected impact of fostering/adopting on all members of the household. |
| | | |
| |Are there any individuals other than children of the caregivers currently living with the family? |
| | Yes No |
| |If yes, describe the impact of those individuals on family functioning. |
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|CHILDREN |
| |For each child currently living in the home describe the following: |
| |Identifiers: name, birth date, race (if different from parents’) school and grade, and or employment. |
| |Date of placement. |
| |Parents’ description of child’s personality, interests, activities. |
| |General adjustment, note if any involvement with law enforcement or the criminal justice system. |
| |Workers assessment of child’s adjustment, development, special needs, relationship with parents and other strengths and weaknesses. |
| |Child’s ideas and attitudes about fostering/adopting based on interview with the child. |
| |Child’s description of the discipline techniques used in the family. |
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|HEALTH |
| |For each member of the household, both adult(s) and child(ren), include the following: |
| |Physical, mental and emotional health and substance use history. |
| |Indicate current health status; including all prescribed medications. |
| |Describe current substance use patterns, history if indicated. If there is a past substance use problem including alcohol use, give particulars, indicate how |
| |diagnosed, resolved, and when. |
| |Does person smoke? If yes, do they smoke in the house? |
| |Mental health treatment, if any, both current and in the past. |
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|PARENTING |
| |Parenting skills, attitudes, and values toward children. |
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| |Knowledge of child development; e.g., appropriateness of expectations of children. |
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| |Understanding of infant care, if applicable. |
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| |Ability to provide infant care; equipment, safety measure in place (e.g. gates, monitor, car seat, play area, pets). |
| | |
| |Safe sleeping requirements have been trained and reviewed. |
| | Yes N/A |
| |Substitute care arrangements – child care arrangements if caregiver(s) work outside of the home. |
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| |Child care for other situations; e.g., appointments, planned social events. |
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|BEHAVIOR MANAGEMENT |
| |Have the caregiver describe behaviors that may require intervention. |
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| |Describe how the caregiver will intervene/handle difficult behaviors. |
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| |Methods of discipline. If the family has used spanking or other corporal punishment, or was raised with it, document their current attitudes. |
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| |Describe the caregiver’s awareness of other forms of discipline; e.g., positive and negative methods. |
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|MOTIVATION |
| |Reasons for wanting to provide care for relative foster/adoptive children. |
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| |Each member’s attitude toward accepting a relative foster/adoptive child. |
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| |Previous experience in providing child foster care, child day care, or adult foster care. |
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| |Previous licenses, including applications that did not result in a license. |
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| |Previous adoptive evaluations or placements. |
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| |Level of understanding of foster/adoptive care and the potential impact of their family. |
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| |Caregiver(s) agree to encourage visits and follow health care, religious and discipline policies of this agency. |
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|FAMILY’S ATTITUDES TOWARD THE CHILD(REN)’S PARENTS AND WORKING WITH THE AGENCY |
| |Describe the caregiver’s understanding of permanency and concurrent planning, including: |
| |The understanding of the child’s permanency goal. |
| |For children with a goal of reunification- the understanding that child welfare staff will be working with the parents to return the child(ren) home. |
| |Whether the caregiver(s) are supportive of the child(ren) returning to his/her parent. |
| |The caregiver’s openness to maintaining significant relationships and supervising visits. |
| |The caregiver’s willingness and ability to provide for the child(ren) long-term, if necessary. |
| | |
| |Describe the caregiver’s willingness to participate and comply with the child(ren)’s case plan, including cooperation with the following: |
| |Supervising agency. |
| |School system. |
| |Child(ren)’s therapist. |
| |Parenting time plan and the treatment plan. |
| | |
| |Describe the caregiver’s willingness to protect the child(ren) from further harm, including the caregiver’s ability to protect the child from unapproved contact|
| |with the parents. |
| | |
| |Describe the caregiver’s attitudes toward the parents, including: |
| |How the caregiver(s) will discuss the birth parents with and around the child(ren). |
| |The caregiver’s relationship and emotional attachment to the child’s parents. |
| |The caregiver’s willingness and ability to speak positively about the parents? If not, assess their ability to understand the negative impact this may have on |
| |the child(ren). |
| | |
| |Describe how the caregiver(s) will discuss with the children the reasons that they entered foster care. |
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| |Does the caregiver(s) agree to not release the child(ren) to anyone, including parents, without the supervising agency’s approval? |
| | Yes No |
| |Does the caregiver(s) agree to not allow the child(ren)’s parents to live in the home without the supervising agency’s approval? |
| | Yes No |
| |Does the caregiver’s understand the home cannot be licensed if the child(ren)’s parents live in the home. |
| | Yes No |
|RECOMMENDATIONS (Must be consistent with the information contained in the report.) |
|Summary of strengths and areas for growth and attention. Include factors considered to determine that the placement is in the child’s best interest. |
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| APPROVAL DENIAL |
|If the recommendation is that the placement should not be made, the reasons for this must be explained in detail. |
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|Relative Assessment Submitted by: |
|Name | | | |
|Agency | | | |
|Title | | | |
|Date | | | |
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|Supervisor Name | | | |
|Agency | | | |
|Title | | | |
|Date | | | |
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|If applicable, complete when additional approval is required. | | |
|Director Signature | | | |
|Agency | | | |
|Title | | | |
|Date | | | |
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|The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, |
|color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. |
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