DHS-599, Foster Care Supportive Visitation and In-Home ...
|FOSTER CARE SUPPORTIVE VISITATION AND |
|IN-HOME PARENT EDUCATION REFERRAL |
|Michigan Department of Health and Human Services |
|Referral Date |FCSV Assigned Date |Referring County |Referring Agency |
| | | | |
|Case Number |Case Name |Date of Removal |
| | | |
|Current Federal Permanency Goal |
| |
|Caseworker Name |Caseworker Email |
| | |
|Caseworker Phone Number |On-Call/Emergency/After Hours Number |Caseworker Fax Number |
| | | |
|Supervisor Name |Supervisor Email |
| | |
|Supervisor Phone Number |On-Call/Emergency/After Hours Number |Supervisor Fax Number |
| | | |
|MDHHS Monitor Name |MDHHS Monitor Phone Number |MDHHS Monitor Fax Number |MDHHS Monitor Email |
| | | | |
| |
|ELIGIBILITY CRITERIA |
|The client must have an open foster care case, with a current goal of Reunification, and whose children have been in out-of-home placement for eight months or less. |
| |
|1. Is current goal Reunification? | Yes No |
|2. Has child(ren) been in out-of-home placement for eight months or less? | |Yes | |No |
| |
|If answered yes to all questions, client is eligible for referral of services. |
| |
|Mother’s Name |Date of Birth |Referred Parent |
| | | |Yes | |No |
|Home Phone |Cell Phone |
| | |
|Street Address |
| |
|City |State |Zip Code |
| | | |
|Has parent been informed of this specific referral? |Has parent expressed willingness to participate in program? |
| |Yes | |No | |Yes | |No |
|Is the parent currently in compliance with their case plan |The most recent court date |
| |Yes | |No | |
|Is a goal change being recommended? |If yes, describe. |
| |Yes | |No | |
|Next FTM date |Is the parent employed? |If yes, what are their hours/shift? |
| | |Yes | |No | |
|Does the parent have any pending legal charges that could result in incarceration in the next 15 weeks? |
| |Yes | |No |
| |
|Father’s Name |Date of Birth |Referred Parent |
| | | |Yes | |No |
|Home Phone |Cell Phone |
| | |
|Street Address |
| |
|City |State |Zip Code |
| | | |
|Has parent been informed of this specific referral? |Has parent expressed willingness to participate in program? |
| |Yes | |No | |Yes | |No |
|Is the parent currently in compliance with their case plan |The most recent court date |
| |Yes | |No | |
|Is a goal change being recommended? |If yes, describe. |
| |Yes | |No | |
|Next FTM date |Is the parent employed? |If yes, what are their hours/shift? |
| | |Yes | |No | |
|Does the parent have any pending legal charges that could result in incarceration in the next 15 weeks? |
| |Yes | |No |
|To add more children, copy the five rows below and paste them below. To ensure entire row is selected, place cursor outside of the table next to the row and drag cursor |
|down to highlight all five rows. |
|Children’s Name |Date(s) of Birth |Genders |Caregiver(s) Name |
| | | | |
|Phone Numbers |Address(es) |
| | |
| |
|Place cursor in front of this sentence and paste additional child rows. |
|Other Services Family Is Receiving |
|Service Provider |Comments |
| | |
| | |
| | |
|Describe the Current Visitation Schedule |
| |
|Are visits scheduled in the home? |If no, why not and where will they be held? What is the plan to have visits in the home? |
| |Yes | |No | |
|Identify all persons not allowed at the visitation |
|Name |Reason Not Allowed at Visitation |
| | |
| | |
| | |
|Reasons Why Child Came into Care |
| |
|Goals and Objectives Identified by Referring Worker |
| |
|Attach Copy of: |
| |Removal Petition |
| |ISP |
| |USP |
| |Other | | |
| |
|Safety Concerns |
| |
|Comments |
| |
|SIGNATURES |
|Referring Worker’s Signature |Referring Supervisor’s Signature |
| | |
|MDHHS Authorization of Services |MDHHS Authorized Signature |Date |
| |Approved | |Denied | | |
|Reason for Denial (if applicable) |
| |
| |
|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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