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:       |

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|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. |

| | | |

| | | |

| | | |

| | |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. |

| | |      |

|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?) |

| |      |

| |Explanation of proposed sleeping arrangement for family members and foster children/adoptive children. Include room sizes and beds currently in rooms. |

| |      |

| |Description of play space. |

| |      |

| |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. |

| |      |

| |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. |

| |      |

| |Where are medications stored, if applicable? |

| |      |

| |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. |

| |      |

|FINANCIAL AND EMPLOYMENT STATUS |

| |Date family provided the DHS-Pub-457 for children in relative care. |

| |      |

| |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? |

| |      |

| |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? |

| |      |

|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. |

| | |      |

| | |Challenges, stressors, any history of help-seeking. |

| | |      |

| | |Losses and coping mechanisms. |

| | |      |

| | |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. |

| |      |

|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. |

| |      |

|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. |

| |      |

|PARENTING |

| |Parenting skills, attitudes, and values toward children. |

| |      |

| |Knowledge of child development; e.g., appropriateness of expectations of children. |

| |      |

| |Understanding of infant care, if applicable. |

| |      |

| |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. |

| |      |

| |Child care for other situations; e.g., appointments, planned social events. |

| |      |

|BEHAVIOR MANAGEMENT |

| |Have the caregiver describe behaviors that may require intervention. |

| |      |

| |Describe how the caregiver will intervene/handle difficult behaviors. |

| |      |

| |Methods of discipline. If the family has used spanking or other corporal punishment, or was raised with it, document their current attitudes. |

| |      |

| |Describe the caregiver’s awareness of other forms of discipline; e.g., positive and negative methods. |

| |      |

|MOTIVATION |

| |Reasons for wanting to provide care for relative foster/adoptive children. |

| |      |

| |Each member’s attitude toward accepting a relative foster/adoptive child. |

| |      |

| |Previous experience in providing child foster care, child day care, or adult foster care. |

| |      |

| |Previous licenses, including applications that did not result in a license. |

| |      |

| |Previous adoptive evaluations or placements. |

| |      |

| |Level of understanding of foster/adoptive care and the potential impact of their family. |

| |      |

| |Caregiver(s) agree to encourage visits and follow health care, religious and discipline policies of this agency. |

| |      |

|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. |

| |      |

| |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. |

|      |

| APPROVAL DENIAL |

|If the recommendation is that the placement should not be made, the reasons for this must be explained in detail. |

|      |

|Relative Assessment Submitted by: |

|Name |      | | |

|Agency |      | | |

|Title |      | | |

|Date |      | | |

| |

|Supervisor Name |      | | |

|Agency |      | | |

|Title |      | | |

|Date |      | | |

| | | |

|If applicable, complete when additional approval is required. | | |

|Director Signature |      | | |

|Agency |      | | |

|Title |      | | |

|Date |      | | |

| | | | |

|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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