ࡱ>  bjbj .||P V8 8 8 8 8 TlT <n!|%%%%m&1(-)u9$;;;;;;$:>@;8 )m&m&));8 8 %%<666)F8 %8 %u96)u9666%`s')6a9<0<6|A*|A6|A8 6|))6)))));;1)))<))))|A))))))))) : HOME STUDY OUTLINEMichigan Department of Health and Human ServicesIDENTIFYING INFORMATIONCase NameCase ID; FORMTEXT       FORMTEXT      Child(ren) s NameChild(ren) s Person ID FORMTEXT       FORMTEXT      Worker NameOrganizationPhone Number FORMTEXT       FORMTEXT       FORMTEXT      EmailDatePlacement Date FORMTEXT       FORMTEXT       FORMTEXT      Children s Name and Age(s): FORMTEXT      1.Name of Caregiver(s): FORMTEXT      Address: FORMTEXT      Phone Number: FORMTEXT      2.Household Members:NAMEDOBSS#*RELATIONSHIP TO CHILDID CONFIRMED  MACROBUTTON [1] "Click Here and Type"  Date child entered care: FORMTEXT MM/DD/YYYYDescribe the family connection which makes up the relation.  MACROBUTTON AcceptAllChangesInDoc  MACROBUTTON[1]"Click HERE and Type"  MACROBUTTON[1]"Click HERE and Type"  MACROBUTTON [1] "Click Here and Type"  * Social Security Numbers must be redacted from all written reports.3.Dates of contact with household members, including on-site visit:DATETYPE OF CONTACT  MACROBUTTON [1] "Click Here and Type"  MACROBUTTON [1] "Click Here and Type"  4.Date Home Study Completed: FORMTEXT      5.Date of Criminal History Check: FORMTEXT      Results of Criminal History Check: FORMTEXT       FORMCHECKBOX N/A: No Criminal Historya.If there is a criminal history, is the conviction for child abuse/neglect, spousal abuse, a crime against children (including pornography) or crime involving violence, rape, sexual assault or homicide, but not including other physical assaults or battery? FORMCHECKBOX Yes:Placement is prohibited: Document reason and rationale for denying the placement. FORMCHECKBOX No:List all other offenses. Describe the length of time since the offense, any services completed that rectified the situation, and any threatened risk of injury or harm to the child placement.  MACROBUTTON [1] "Click Here and Type"  b.Address any risk factors that might impact the safety of the child and describe what protective interventions are in place currently. FORMTEXT      6.Date of Central Registry Check: FORMTEXT      Results of Central Registry Check: FORMTEXT       FORMCHECKBOX N/A: No CPS History FORMCHECKBOX Yes, there is a history of abuse/neglect.a.If there is a history of abuse or neglect, describe the length of time since the substantiation and any services that have been provided to rectify the problem(s). FORMTEXT      b.Address any risk factors that might impact the safety of the child and describe what protective interventions are in place currently. FORMTEXT      7.Caregiver(s) Relationship Status:Is the caregiver involved in a relationship? FORMTEXT      Describe the relationship. Describe strengths of the relationship & areas in need of work or attention. Describe how the couple handles stress, decision making, etc. FORMTEXT      Is that person living in the home? FORMTEXT      Have there been any incidents of domestic violence in the relationship? FORMTEXT      Is there a history of domestic violence for the caregiver or any other household member? Describe. FORMTEXT      8.Substance Abuse:Does the caregiver or any household member have a substance abuse or alcohol concern? FORMTEXT      Is there a history of substance abuse or alcohol concerns or treatment for any household member? FORMTEXT      9.Mental Health:Describe and evaluate the current mental and emotional health of the caregiver(s) and household members. Is there a history of mental health problems or treatment for the caregiver or any household member including marriage counseling or counseling for the child(ren)? Include current prescriptions for psychotropic medications and reasons for prescribed medications. FORMTEXT      10.Physical Health:Describe the caregiver(s) physical health. If physical health condition is noted, describe how condition would affect the care of the child(ren) in the home. FORMTEXT      11.Financial/Employment Status:List$(   $ & ( 2 4 , . B D F P R T V j l n x z | ~ jhdUj"hdUjhdUj&hdUjhdUjhdUjhdUmHnHujhdUjhdUh0hd5hCyhdhu+6&(sg 0$$Ifa$gd#<kdZ$$If9++4 9aytu+ '$Ifgdu+<kd$$If9$++4 9aytu+ *$Ifgdu+ 6 cZZ -$Ifgd#Rkd$$If94$0+4 9af4yt# $Ifgd#?kd$$If94++4 9af4yt#6 8 \ SJJ -$Ifgd#Rkd$$If94$0+4 9af4yt# $Ifgd#Okd$$If90+4 9ayt#  * , T @7 -$Ifgd#ekd($$If94$Fe+    4 9af4yt# $Ifgd#Okd$$If90+4 9ayt#T | $Ifgd#bkd$$If9$Fe+    4 9ayt# -$Ifgd#  , T V -bkdr $$If9$Fe+    4 9ayt# -$Ifgd#ekd$$If94$Fe+    4 9af4yt#       ( * , . 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Are they adequate to meet the needs of the placement? If income is based on disability, i.e., SSI, Social Security Disability, long term disability payments from a job, workmen s compensation, etc., there must be an assessment of how that impacts the ability to care for the child(ren). FORMTEXT      12.Day Care and Supervision:Discuss the caregiver(s) plans for day care if necessary. FORMTEXT      What arrangements would be made for alternative care for the child(ren) if the caregiver is unavailable? FORMTEXT      13.Sleeping Arrangements:View and describe the sleeping arrangements for the child(ren). If the child(ren) is 12 months of age or younger, describe the caregiver s understanding of and willingness to abide by safe sleep practices. FORMTEXT      14.Motivation for Placement of the Child(ren): Attitude of each member of the household toward accepting the child(ren). Attitudes towards the birth parent(s). FORMTEXT      15.The Capacity for and Willingness to Support the Case Plan for the Child(ren) in Their Care: Discuss the caregiver s capacity and willingness to cooperate with the supervising agency, the school system, child s therapist, the parenting time plan outlined in the treatment plan, etc. Address the caregiver s ability to protect the child(ren) from further harm. FORMTEXT      16.Family s Willingness to Work with the Child s Birth Family: Do the caregiver s agree that they will not allow the child(ren) s parent(s) to live in the home without the agency s approval? Do the caregiver s agree to not release the child(ren) to anyone, including birth parents, without the supervising agency s approval? FORMTEXT      17.Family Methods of Behavior Management and Discipline of Children: Are the caregiver s willing to follow the supervising agency s discipline policy? Discuss the caregiver s method of behavior management.  FORMTEXT      18.Discuss the caregiver s capacity for parenting relative to the child(ren) s age and developmental needs. Describe their capacity and disposition to give the child(ren) guidance, love, and affection. FORMTEXT      19.Is the caregiver committed to providing a stable living environment for the duration of placement? Describe the caregiver s ability to provide permanence if necessary. FORMTEXT      20.Conclusion: Based on information gathered, summarize the caregiver s functioning as it applies to their capacity to care for the child(ren). FORMTEXT      21.Recommendation: Placement with caregiver s is Approved/Denied  FORMTEXT      Foster Care Worker s Signature:Date:Foster Care Supervisor s 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. cc:Case FileCourtParent(s)  See policy. Redact Central Registry and LEIN information.     DHS-197 (Rev. 5-15) Previous edition obsolete. 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