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 | | |Status (Withdrawn/Approved/Denied) date | |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 | | |Status (Withdrawn/Approved/Denied) date | |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 | | |Status (Withdrawn/Approved/Denied) date | |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 | | |Status (Withdrawn/Approved/Denied) date | |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