ࡱ> 8:567O bjbj ;\օeօegV V 84w%%%%&VI',u'3333333$6693'&&''3%%H4222'%%32'3222%XZU*2340429U*f9292@''2'''''33.'''4''''9'''''''''V a: Family Team Meeting ReportMichigan Department of Health and Human ServicesDemographicCase Name:Case ID:Special Needs:  FORMCHECKBOX  YES  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT      Race/Ethnicity:  FORMDROPDOWN Native American Affiliation FORMTEXT       FORMTEXT       FORMTEXT      Youth s Name and Child(ren) s Person ID#:Youth s DOB:Is Youth placed in residential:  FORMCHECKBOX  YES  FORMCHECKBOX  No FORMTEXT       FORMTEXT      Is youth YAVFC?  FORMCHECKBOX  YES  FORMCHECKBOX  NoCase Opening Date:Initial Removal Date:Security Needs:  FORMCHECKBOX  YES  FORMCHECKBOX  No FORMTEXT       FORMTEXT      Please Describe Security Needs:Initial Petition Date:Mandatory Petition:  FORMCHECKBOX  YES  FORMCHECKBOX  No FORMTEXT       FORMTEXT      Worker Name:Worker Phone Number:Work Load Number: FORMTEXT       FORMTEXT       FORMTEXT      FTM InformationDate/Time FTM request initiated:Date of Pre-Meeting Discussion:Facilitated by Case Manager:  FORMCHECKBOX  YES  FORMCHECKBOX  No FORMTEXT       FORMTEXT      If no, name of facilitator:  FORMTEXT      Suggested meeting date/time:Date Meeting Scheduled:If meeting is facilitated by someone other than the Case Manager, please document justification here: FORMTEXT       FORMTEXT       FORMTEXT      Meeting Location:  FORMDROPDOWN Location Address:Identify Other Location: FORMTEXT       FORMTEXT      Signature of supervisor approving another facilitator: FORMTEXT      FAMILY TEAM MEETING REPORT Michigan Department of Health and Human ServicesFTM Type 1:FTM Type 2:FTM Type 3: FORMDROPDOWN  FORMDROPDOWN  FORMDROPDOWN Agenda items as identified at the pre-meeting discussion: FORMTEXT      Participants as identified at the pre-meeting discussion: FORMTEXT      FAMILY TEAM MEETING REPORTMichigan Department of Health and Human ServicesCase Name:Case ID:Date & Time of FTM: FORMTEXT       FORMTEXT       FORMTEXT      Families/Youth Strengths: FORMTEXT      Family/Youth NeedsAction StepsTime FramePerson (s) Responsible FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT  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!"!,!.!0!2!F!H!J!T!V!X!Z!n!p!r!|!~!!!!˵˪ϣ˘ˍ˂jXhPUjXhPUj'XhPU h hAjWhPUjVhPUjCVhPUhPhhAOJQJ^JaJjhPUmHnHujhPUjUhPU2!!0!X!!!offff $IfgdAkdW$$Ifl\1"l+ : t44 lap(yt!!!!!!!!!!!"HJLNbdfprtvȹϹϰϹϹϹ쬡쬖쬋쬀j\hPUj\hPUj+\hPUj[hPUhPU h h hh OJQJ^JaJ h hAhhAOJQJ^JaJjhPUmHnHujhPUjeYhPU2!!!!!!offff $Ifgd]kdY$$Ifl\1"l+ : t44 lap(yt!!!Joffff $Ifgd]kduZ$$Ifl \1"l+ : t44 lap(ytpsTime FramePerson (s) Responsible FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Recommendations & Ratioinale: FORMTEXT       Family Team Meeting Attendance ReportDate:Michigan Department of Health and Human Services FORMTEXT      Parent Confidentiality Statement: I understand that sensitive and confidential information regarding my case (including, but not limited to treatment and records of substance abuse, mental health and/or medical issues) may be discussed at this meeting for purposes of case planning, may be included in a case plan, and may be shared with the court. I give my permission for this information to be discussed and understand that I can revoke my consent to these discussions and/or request the exclusion of individuals from certain conversations or can end my participation in this meeting. I also understand, that any new information regarding possible allegations of child abuse or neglect must be reported to Children s Protective Services. Print Name:Print Name:Print Name:Signature:Signature:Signature:Role:Date:Role:Date:Role:Date:Print Name:Print Name:Print Name:Signature:Signature:Signature:Role:Date:Role:Date:Role:Date:Team Member Confidentiality Statement: In accordance with the policies of Michigan Department of Health and Human Services (MDHHS) and any applicable provisions of the Michigan law, I understand that as a member of this Family Team Meeting (FTM) I will have access to confidential information about an individual s or a family s involvement with MDHHS. I understand that my access to this information is limited strictly to the information necessary to carry out my role as part of the family team. I will not share information received at a family team meeting concerning a child or family member with anyone who is not part of the case planning process. Any new information regarding possible allegations of child abuse or neglect must be reported to Children s Protective Services. Print Name:Print Name:Print Name:Signature:Signature:SignatureRole:Role:Role:Print Name:Print Name:Print Name:Signature:Signature:Signature:Role:Role:Role:Print Name:Print Name:Print Name:Signature:Signature:SignatureRole:Role:Role:     DHS-1105 (Rev. 9-18) Previous edition obsolete.  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