DHS-1295, Young Adult Monthly Visit Report
|Young Adult Monthly Visit Report |
|Michigan Department of Health and Human Services |
|Young Adult Voluntary Foster Care Program |
|This report must be completed and used to guide discussion and identify needs. If a need is indicated, the caseworker must address the need by providing or referring to |
|a service and document the action taken in the service plan. Monthly verification of eligibility for YAVFC is required. |
|Youth’s Name |Visit Location |Visit Date |
| | | |
|Participants |
| |
|List any changes in the home/address, including who resides in home. |
| |
|Assessment of home (sanitary concerns, safety or privacy issues, etc.). |
| |
|Is there anything from the last visit that is still a concern? | Yes | No |Provide explanation. |
| |
|Top priorities for this visit |
|1. | | |
|2. | | |
|3. | | |
| |
|Does the youth need any of the following documents |
| Birth Certificate | Dental Records | School History |
| Med Records/Info | Contact Information | Immunization Record |
| Address History | Health Insurance Card | State ID Card |
| Social Security Card | Driver’s License | Selective Service Card |
| Diploma/GED | Mental Health Info | Other: | |
|Eligibility for YAVFC based on (check one or more) |
| Employment | Education | Volunteering | Medical Disability |
|Continued eligibility documented for the month of: | | |
| | | |
|Verification received (ie pay stubs, proof of enrollment, etc.) |
| |
|Physical/Mental Health (concerns, appointments, treatment, follow-up care, therapy, status of SSI application, etc.) |
| |
|Medication (dosage, physician, diagnosis, changes, etc.) |
| |
|Upcoming Appointments |
| Semi-Annual Transition Meeting: | | |
| Next Home Visit: | | |
| Upcoming Medical/Dental Appointments: | | |
| Other: | | |
| |
|Contact Information |
| Update the following, if applicable |
| | Phone | | |
| | Email | | |
| | Text | | |
| |
|Follow-up activities identified during this visit |Person Responsible |Target Date |
|1. | | | |
|2. | | | |
|3. | | | |
|Youth’s Signature |Date |
| | |
|Foster Care Provider Signature (if applicable) |Date |
| | |
|Case Worker Signature |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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