Adoption Checklist - Michigan



|ADOPTION CHECKLIST |

|Michigan Department of Health and Human Services |

| |

|Child(ren)’s Name(s) |      |Birth Date(s) |      |

| |

|Date Referred for Adoption |      |Commitment Date(s) |      |

| |

|Referring Agency |      | | |

| |

|Documentation Received: |

| |Original Birth Certificate(s) |      |

| |Termination/Commitment Order |

| |Initial/Updated Service Plans, date of last USP received |      | |

| |Social Security Card(s) |

| |Funding Source |      | |

| |DOC Rate |      | |DOC expiration date |      | |

| |Current Medical (DHS-1663) |

| |Dental (DHS-1664) |

| |Native American? | Yes No |

| |Psychological Reports |

| |Currently in Therapy? | Yes No |Therapist name |      | |

| | |Therapist contact information |      |

| |School Reports (IEPs, Report Cards) |

| |Early On/Developmental Records |

| |Placement History |

| |Picture |

| |Birth Records |

| |

|Foster Parent Notification (DHS 4809) |

|Date Sent |      | |

|Date Response received |      | |

|Interested: | Yes No |

| |

|Relatives identified in case or expressing an interest in adoption: |

| |Relative Search forms |

| |Relative Assessment |

|Name/Relationship |

|1. |      | |Status (Withdrawn/Approved/Denied) date |      |

|2. |      | |Status (Withdrawn/Approved/Denied) date |      |

|3. |      | |Status (Withdrawn/Approved/Denied) date |      |

|4. |      | |Status (Withdrawn/Approved/Denied) date |      |

| |

|Competing Parties: Yes No |If yes, name |      |relationship |      |

| |name |      |relationship |      |

| |name |      |relationship |      |

| |name |      |relationship |      |

| |

|Child Adoption Assessment/Court Reports: |

| |Initial Case Conference |Date |      | |

| |Met child/caregiver |Dates |      | |

| |Written Assessment (DHS-1927) |Date |      | | |Addendum |Dates |      | |

| |Quarterly reports |Dates |      | |

| |

|MARE/Recruitment: |

| |Let’s Talk About … |

| |MARE Photo |

| |MARE Photo Listed Date |      | |

| |MARE Hold Date |      | |Type of hold |      |

| |Child specific recruitment plan |      |(date) |

| |6-month hold |      |(date) |

| |

|Adoptive Family: |

| |Identified |      | |

| |Recruitment Needed |

| |

|Adoptive Family Assessment: |

| |Orientation |Date |      | |

| |Publications given (DHS-255, 823, and 538) |

| |Application (DHS-3153-A) Is family licensed? | Yes No |

| |Record Clearances complete |      |(date) |

| |Local Clearances |      |(date) |

| |Fingerprinting |      |(date) |

| |ICHAT |      |(date) |

| |Personal References |

| |Professional References (If applicable) |

| |Adult Child References |

| |Marriage License |

| |Divorce Decree, if applicable. |

| |Death Certificate, if applicable. |

| |Birth Certificate(s) |

| |Social Security Card |

| |Driver’s License |

| |Income Verification |

| |Child Support Documentation, if applicable. |

| |Previous Orders of Adoption |

| |Military Discharge, if applicable. |

| |Therapy reports, if applicable. |

| |Freedom of Information form, if applicable. |

| |Medicals |      |(date) |

| |Written Assessment (DHS-3130 or 612 or 1926) |

| |Family received copy of AFA (recruited/MARE match) |

| |Shared history/Verification signed by adopting parents (DHS-4818) |

| |Family PRIDE training |

| |

|Adoption Assistance Application: |

| |Adoption Assistance/NRE Intent Statement (DHS-4081) |

| |Adoption Assistance and/or Medical Subsidy Application (DHS-1341) |

| |Supporting Documentation |

| |Adoption Assistance Rate Negotiation/Determination Worksheet (DHS-959) |

| |Verify Foster Payment |Rate |      | |

| |DOC (DHS-470 or DHS-1945) |Rate |      | |

| |Date application routed to Adoption Assistance Office |      | |

| |Agreement received |

| |Signed by Parent |

| |Signed by Subsidy Manager |Date |      | |

| |Agreement given to Parent |Date |      | |

| |Agreement uploaded to MiSACWIS |Date |      | |

| |

|MCI Consent Request: |

| |Birth Certificate |

| |Termination/Release Order |

| |CAA and addendum(s) |

| |AFA and addendum(s) |

| |Licensing Complaints/Corrective Action Reports/CPS Reports |

| |DHS-3217 |

| |PCA-309 |

| |Not recommending Letter (DHS-605) (if applicable) |

| |Expedited | Yes No |County |      | |

| |Date request routed to MCI or County Office |      | |

| |Date Consent received |      | |

| |

|Court Packet: |

| |Petition for Adoption (PCA-301) |

| |Order Following Hearing to Terminate Parental Rights (JC-63) |

| |Order Following Hearing Terminate Parental Rights (PCA-318) |

| |Order Placing Child After Consent (PCA-320) |

| |Order of Adoption (PCA-321) |

| |Statement of Services Performed by Agency/Department of Human Services (PCA-345) |

| |Petitioner’s Verified Accounting (PCA-347) |

| |Final Order Allowing Fees and Costs (PCA-341) |

| |Consent to Adoption by Adoptee (PCA-307), if child is 14 years old or older. |

| |Notice to Adopting Parents on Pending or Potential Appeal/Rehearing (PCA-325) and Appellate Letter. |

| |Birth Certificate |

| |Consent (PCA-309) |

| |CAA and addendums |

| |AFA and addendums |

| |ISP/USP |

| |Medicals |

| |Form to Establish a New Michigan Birth Record (DCH-894) |

| |Other |      | |

| | |      | |

| | |      | |

| | |      | |

| | |      | |

| | |      | |

| |

|Adoption Supervision: |

| |Supervision? | Yes No |

| |Birth Parent Appeal Pending | Yes No |

| |Supervision Reports (DHS-613) |Dates |      | |

| |PCA-320 sent to MARE. |Date |      | |

| |

|Closing Summary (DHS-222): |

| |Closing Letter |

| |Records to closed files |

| |Assistance Payment Request (DHS-1344) |Date routed to Adoption Assistance Office |      | |

| |Nonrecurring Expense Claim for Reimbursement |

| |Final Order of Adoption (PCA-321) |Date of order |      | |

| |Final order sent to Adoption Assistance Office |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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