Children's Foster Care Relative Placement Home Study
|CHILDREN’S FOSTER CARE |Case # | |
|RELATIVE PLACEMENT HOME STUDY |Case Name | |
|Michigan Department of Human Services |Worker Name | |
| |Worker Title | |
| |Agency Name | |
| |Placement Date | |
| |Home Study Type: Initial Annual |
| |
|CHILDREN’S NAMES AND AGES |
| |
|NAME OF CAREGIVER(S): | |
|ADDRESS: | |
|TELEPHONE NUMBER: | |
|EMAIL ADDRESS: | |
|DATE HOME STUDY COMPLETED: | |
| |
|DIRECTIONS TO THE HOME |
| |
| |
|RELATIONSHIP |
| |
|Describe how the child is related to the prospective caregiver. Describe the legal relationship. |
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| |
|MEMBERS OF THE HOUSEHOLD (Tab through cells to add additional rows) |
|NAME |DOB |RELATIONSHIP TO CAREGIVER |
| | | |
| | | |
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|SOCIAL WORK CONTACTS (Tab through cells to add additional rows) |
|DATE |PERSONS |TYPE OF CONTACT/PLACE |
| | | |
| | | |
| | | |
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|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 all offenses. Describe the length of time since the offense and the services completed |
| | |that rectified the situation. Address safety risks and identify protective interventions. |
| | | |
| |
|Date of Michigan Central Registry Check: | | |
| |Central Registry Results: |
| | |N/A: Not found |
| | |Yes, there is a history of child abuse or neglect. |
| | |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. |
| | | |
| |
|*If there is any household member who is on central registry, THE HOME CANNOT BE LICENSED. Pursue a waiver if determined the child(ren) is safe in the home. |
| |
|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?) |
| | |
| |Description of play space: |
| | |
| |Safety considerations: |
| | |Are there pets in the home? Yes No If yes, does the pet have current vaccinations? Yes No |
| | |ii. Pet Attributes: Explain what makes the pet friendly or a safety concern. Describe how the pet interacts with household members and strangers who |
| | |visit the home. |
| | | |
| | |Are there water hazards on or near the premises? Yes No If yes, describe how the caregiver plans to safeguard children around them. (Water hazards|
| | |include pools, ponds, etc.) |
| | | |
| | |Are there working smoke detectors on each floor, and between each sleeping area and the rest of the home? Yes No |
| | |Is there a working carbon monoxide detector installed as recommended by the manufacturer? |
| | |Yes No |
| | |Are there weapons in the home? Yes No If yes, describe type and how stored. Firearms must be trigger-locked or fully inoperable and stored without|
| | |ammunition in a locked area. Ammunition must be stored in a separate locked location. |
| | | |
| |Sleeping Arrangements. Explain the proposed sleeping arrangements for family members and foster/adoptive children. Include room sizes and number of beds |
| |currently in the rooms. |
| | |
| |
|Size of Bedroom |# and Type of Bed(s) |Occupants |
|1 | | | |
|2 | | | |
|3 | | | |
| |
|(Tab through cells to add additional rows) |
|Do all bedrooms have a window and a door that can be used to get out of the home in an emergency? |
| | |Yes. |
| | |No. Explain: |
| | |
|Are members of the household using rooms that are primarily used for purposes other than sleeping as a bedroom? |
| | |Yes, include a description of the room. |
| | |
| | |No. |
| |
| |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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|DAY CARE OR SUBSTITUTE CARE |
| |Describe plans for day care or substitute care. |
| | |
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|FINANCIAL AND EMPLOYMENT STATUS |
| |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. |
| | |
| |
|Recipient |Source |Monthly Amount |
| | | |
|(Tab through cells to add additional rows) |
| |
|Assess the caregiver’s money management skills and ability to meet family needs with current income. Is the caregiver(s) current on their bills? Can the |
|caregiver(s) meet the financial expenses of having a relative child placed in the home prior to payments starting? Discuss what sources of financial support are |
|available to the caregiver(s) until licensed. Include specific needs the caregiver may have for startup costs, such as: bed, smoke detectors, etc. |
| |
| |
|If income is based on disability, (e.g., SSI, RSDI, long term disability payments from a job, workmen’s compensation) there must be an assessment of how the |
|disability impacts the ability to provide relative care or be a member of the household. |
| |
| | |Income is based on caregiver’s disability but does not impact ability to care for the child(ren). |
| | |Describe how this assessment was determined. |
| | |
| |
| | |Other, please explain. |
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|Date caregiver(s) was provided with information regarding Ineligible Grantee Funds, Medicaid, Food Assistance, WIC: |
| | |
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|FAMILY LIFE |
| |
| |Caregiver’s current relationship. Assess the caregiver’s stability, considering length of relationship, time at current residence, place of employment, and |
| |other appropriate factors. |
| | |Provide brief history, including date and place of marriage, if applicable. |
| | |
| | |Describe any history of separations or domestic violence. |
| | |
| | |Describe strengths of the relationship and areas of work or attention. |
| | |
| | |Describe common/shared interests or lack thereof. |
| | |
| | |Describe roles, division of labor, decision-making process and handling of stress or disagreements. |
| | |
| | |Assess level of satisfaction and stability of the relationship. |
| | |
| | |Describe the relationship with the parent of children, if separated. |
| | |
| |
| |Family. Include assessment of the family in all of the following areas: |
| | |Activities, goals, values, role of religion, and church involvement. |
| | |
| | |Challenges, stressors, and any history of help-seeking. |
| | |
| | |Losses the family experienced and how the family coped. |
| | |
| | |Expected impact of relative placement on all members of the household. |
| | |
| | |Are there any individuals other than children of caregivers currently living with the family? What is the impact of those individuals on family |
| | |functioning? |
| | |
| |
| |Children. For each child living in the home including relatives/foster children, include the following: |
| | |Identifiers: name, race (if different from parents’) school and grade, and/or employment. |
| | |
| | |Parents’ description of child’s personality, interests and activities. |
| | |
| | |General adjustment, note if the child has had involvement with law enforcement or the criminal justice system. |
| | |
| | |Worker’s assessment of child’s adjustment, development, special needs, relationship with parents and others 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. |
| | |
| | |Child’s description of relationship with other parent, if parents are separated. |
| | |
|HEALTH For each member of the household, both adult(s) and child(ren), include the following: |
| |
| |Assessment of physical, mental and emotional health and substance use history. |
| | |
| |Indicate current health status. Is anyone in the household prescribed medication? If so, list the medications. How long has he/she been taking the |
| |medications, what are the medications prescribed to treat? |
| | |
| |If the caregiver(s) or anyone else in the household has a physical or mental health diagnosis or condition, describe how the condition may affect the care of |
| |a child. |
| | |
| |Describe current substance use patterns, and history if indicated. If there is a past substance use concern, including alcohol use, give particulars, indicate|
| |how diagnosed, resolved and when. What is the current treatment? |
| | |
| |Does any member of the household smoke? Yes No If yes, do they smoke in the house? Yes No |
|PARENTING Assess the following: |
| |
| |Parenting skills and attitudes toward children. Assess the bond between the caregiver(s) and his/her birth child(ren). Does the caregiver(s) provide his/her |
| |birth child(ren) with appropriate supervision? What types of disciplines are used by the caregiver(s)? Are they age appropriate? What positive interactions |
| |have you observed between the caregiver(s) and their birth child(ren)? |
| | |
| |Parenting values. |
| | |Describe the caregiver’s view of the most important things for parents to do, what they will do similarly to their parents? What they hope to improve |
| | |upon? |
| | |
| |Describe caregiver’s knowledge of child development, appropriateness of expectations of children. |
| | |
| |Describe caregiver’s ability to provide infant care: Include the following in the assessment: |
| | |λ Equipment and safety measures are in place (e.g., monitor, car seats, play area, pets). Yes No N/A |
| | |λ Understanding of infant care. Yes No N/A |
| | |Safe sleep requirements have been reviewed and trained? Yes No N/A – an infant child is not being considered for placement in this home. |
| | |
| |Describe caregiver’s capacity and disposition to give a relative child guidance, love and affection. Describe how the caregiver will deal with children who |
| |present difficult, unacceptable behavior, or children who are rejecting and/or oppositional, or children with medical needs? |
| | |
| |Interventions: |
| | |What kinds of behavior does the caregiver indicate requires intervention? |
| | |
| | |ii. How will caregiver intervene/handle that type of behavior? How will he/she be supportive and nurture relative child(ren)? |
| | |
| | |Describe the caregiver(s) methods of discipline: Flexibility and age appropriateness of approaches, willingness to follow the case plan for the |
| | |child(ren) if it differs from his/her normal approach to discipline. |
| | |
| | |Describe the caregiver(s) awareness of a variety of techniques, use of positive and negative methods. |
| | |
| |Describe the caregiver(s) understanding of the agency’s discipline policy and willingness to abide by it. If the caregiver(s) has used spanking or other|
| |corporal punishment, or was raised with it, document his/her current attitudes. |
| | |
|MOTIVATION Assess the following: |
| |
| |Describe reasons for wanting to provide care for relative/foster/adoptive children. Describe the caregiver’s emotional attachment to the child(ren). How |
| |frequently has the caregiver(s) had visits, phone calls, correspondence or other types of contact with the child(ren)? |
| | |
| |Describe each member’s attitude towards accepting a relative child. If the caregiver(s) has ever provided care for the child(ren), describe the circumstances |
| |and outcome. |
| | |
| |Caregiver’s level of understanding of relative care and the potential impact on their family. Does the caregiver(s) understand that a caseworker will visit |
| |the child(ren) and caregiver(s) at least monthly until reunification with parents occurs or legal permanency is achieved? Describe the caregiver’s view |
| |regarding the impact of the related child(ren)’s placement on the family. Assess what the caregiver(s) will need to provide care and support to the |
| |child(ren). |
| | |
| |Caregiver(s) agreement to encourage visits and follow health care, religious and discipline policies of the agency. Include if the caregiver(s) is willing to |
| |participate in training. |
| | |
|FAMILY’S ATTITUDES TOWARD THE CHILD(REN)’S PARENTS AND WORKING WITH THE AGENCY |
| |
| |Understanding of permanency and concurrent planning. Does the caregiver(s) understand that child welfare staff will be working with the parents to return the |
| |child(ren) home? Is the caregiver(s) supportive of the child(ren) returning to his/her parent? Does the caregiver(s) agree to participate in case planning? |
| |Will the caregiver(s) provide for the child(ren) long-term, if necessary? |
| | |
| |Caregiver’s willingness to comply with the child(ren)’s case plan: |
| |Is the family willing: |
| | |To cooperate with the supervising agency? |
| | |
| | |To cooperate with the school system? |
| | |
| | |To cooperate with the child(ren)’s therapist? |
| | |
| | |To cooperate with the parenting time plan outlines in the treatment plan? |
| | |
| | |Describe how the caregiver will protect the child(ren) from further harm? |
| | |
| |Attitudes toward the parents. How will the caregiver(s) discuss the parents with and around the relative foster child(ren)? Describe the caregiver’s |
| |relationship and emotional attachment to the child’s parents. Does the caregiver(s) speak positively about the parents? If not, assess their ability to |
| |understand the negative impact this may have on the child(ren). |
| | |
| |How will the caregiver(s) discuss reasons children enter foster care? |
| | |
| |Caregivers understand the goal of the agency in providing foster care and are willing to support the agency towards reuniting a foster child with his or her |
| |family. |
| | |Does the caregiver(s) agree to not release the child(ren) to anyone, including parents, without the supervising agency’s approval? Assess the relative’s|
| | |ability to protect the child from unapproved contact with the parents. |
| | |
| | |Does the caregiver(s) agree to not allow the child(ren)’s parents to live in the home without the supervising agency’s approval? |
| | |
| | |The caregiver’s understand the home cannot be licensed if the child(ren)’s parents live in the home. |
| | |Yes No |
| | |
| |Caregiver’s ability to empathize and work with the parents and child(ren). |
| | |
| |Caregiver’s openness to maintaining significant relationships and supervising visits. |
| | |
| |Caregiver’s openness to provide permanency for the relative child(ren), if needed. |
| | |
|RECOMMENDATIONS (Must be consistent with the information contained in the report.) |
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| |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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| |Areas to be considered in making placements. |
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| |
| | APPROVED DENIED. If the recommendation is that placements should not be made, the reason for this must be explained in detail. |
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|Explanation: |
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|Relative Assessment Submitted by: |
|Name | | | |
|Agency | | | |
|Title | | | |
|Date | | | |
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|Supervisor Name | | | |
|Agency | | | |
|Title | | | |
|Date | | | |
|Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, |
|marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., |
|under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. |
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