ࡱ> {@ _bjbjצצ ,=FFFFFFFZBBB?ZypZD GLVGVGVG1HlI9JP_Ysxxxxxx$E{R}xFJ1H1HJJxFFVGVGy3M3M3MJFVGFVG_Y3MJ_Y3M3M}O|FFPVG+ HwBJ.OQy0y P~JP~$PZZFFFF~F+PXJJ3MJJJJJxxZZ/>AdMZZ>ACHILDREN S FOSTER CAREFC Case Number: FORMTEXT      Parent  Agency Treatment Plan and Service AgreementFC Case Name: FORMTEXT      Michigan Department of Human ServicesDHS FC Worker Load #: FORMTEXT      DHS FC Worker Name: FORMTEXT      PS Case Number: FORMTEXT      PS Case Name: FORMTEXT      Date Completed:  FORMTEXT      Check One:Court ID #: FORMTEXT       FORMCHECKBOX Initial Service PlanPOS Agency Name: FORMTEXT       FORMCHECKBOX Updated Service PlanPOS Agency Worker Name: FORMTEXT      This treatment plan is developed to assure that each child will receive safe and proper care and services by the following activities. CHILD INFORMATIONDHS Case NumberChild NamePermanency Planning Goal CodeTarget DateAnticipated Next Placement TypeDate Anticipated Next Placement FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMDROPDOWN  FORMTEXT       Service Type Code:AD =Alcohol or Drug Abuse RehabilitationFR =Reunification ServicesIL =Independent Living ServicesOT =Other Program NeedsDC =Day CareFC =Family Counseling/Outreach CounselingJT =Job Training/Employment AssistancePS =Parenting Skills TrainingED =EducationHS =Homemaker Services or Parent AidesMH =Mental Health ServicesTH =Individual/Group TherapyDV =Domestic Violence ProgramMD =Medical ServiceWP=Wrap AroundA. SERVICE REFERRAL TABLE To enter additional services for following reports, place the cursor in the FIRST FIELD of the row ABOVE where you want the new row and click the Insert Svc Ref Row button to insert services between rows as needed. To enter continued headings, click in the FIRST FIELD on the new page and click the ADD SVCREF HEAD button. To remove continued headings, click the REMOVE SVC REF HEADING.  Using the codes above for member referred and service provider type, enter the information for all services below. Family Member Name Barriers/ Needs Addressed  Service Type Code  Service Provider Name  Mo/Yr Re- ferred  Mo/Yr Start Target Com- pletion Date (Mo/Yr) Service Status  Completed Services  Com- pletion Date (Mo/Yr)  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       Parent - Agency Treatment Plan and Service Agreement (continued) In this section, provide the specific goals, objectives, activities, and parenting time (schedule and expected activities) for all parties, the placement provider, the child(ren), and the foster care worker with the expected outcome of each activity. The goals and objectives must be clear, measurable, and designed to resolve the primary barriers for reunification identified in the Family Assessment of Needs and Strengths, and to achieve the permanency planning goal.B. Parent/Caretaker Goals and Objectives 1. List each goal for parent(s) and non-parent adult(s), if applicable, specific action steps, time frame for achieving, and expected outcome. Goals must address the areas prioritized on the Family Assessment of Needs and Strengths. 2. If applicable, specify involvement in medical and dental appointments and attendance at school conferences. 3. Indicate if employment, day care, and/or transportation is a barrier to the parent meeting any of the goals or action steps including parenting time. Indicate the plan to address any of these three items.   MACROBUTTON [b2] "Click Here and Type"  C. Foster Parent/Relative Caregiver Activities and Discipline and Child Handling Techniques 1. List each goal for foster parent / relative caregiver, specific action steps, time frame for achieving, and expected outcome. 2. Describe the discipline and child handling techniques to be used while the child is in placement. 3. Describe the plan of supervision for the child while in placement. 4. Describe the plan for acceptable activities such as baby sitting, routine household tasks, privileges etc. 5. If the youth is age 14 or older, detail the independent living preparation activities the foster parent / relative caregiver will provide to assist the youth. (See CFF 722-6 Independent Living Preparation.) 6. Justify the tasks and/or additional expenses provided by the caregiver that justifies the Determination of Care Supplement.   MACROBUTTON [b2] "Click Here and Type"  D. Individual Child Activities 1. List for each child, the service goals and action steps, time frame for achieving, and expected outcome.. Goals should address areas prioritized on Child Needs and Strengths Assessment and activities of daily living (if applicable). Identify what agency and parent(s) need to do to meet these specific needs. 2. Address sibling visitation, if siblings are split. When separated, the relationship between siblings must be maintained by detailed plan of visits, phone calls and letters. 3. For each ward age 14 or older (including those wards who become 14 years of age during the report period), include a description of the programs and services which will assist the youth to prepare for the transition to a state of functional independence or the ability to take care of oneself physically, socially, economically and psychologically. Identify where, how and by whom these services are to be provided. (See CFF 722-6 Independent Living Preparation.) NOTE: The DHS-4713 (Service Youth Profile Report) is completed quarterly for all youth receiving independent living preparation services. See RFF-4713 for instructions of form completion.   MACROBUTTON [b2] "Click Here and Type"  E. Foster Care Worker Activities 1. Identify services to be provided to the parent(s), the child(ren), relative caregiver and to foster parents by the foster care worker. State activities that support the services offered to all participants in the service plan. 2. State proposed foster care worker contact with the family, child(ren), caretakers, and service provider, if applicable. 3. If the youth is age 14 or older, detail the independent living preparation activities the worker will provide to assist the youth. (See CFF 722-6 Independent Living Preparation.) 4. Identify what the worker will do to facilitate parenting time and sibling visitation, if applicable.   MACROBUTTON [b2] "Click Here and Type"  F. Parenting Time Identify the parenting time plan for all parents / caretakers and non-parent adults, if applicable. Identify under worker activities what the agency will do to facilitate parenting time. 1. Specify the type, frequency, location, and duration of parenting time. If less than weekly, specify why. a. State how parenting time setting will assure a family friendly environment. b. If location is other than parental home, specify where and what conditions must exist for in-home visits to take place. 2. If parenting time is supervised, specify by whom and what conditions must exist for unsupervised visit. a. If court is limiting parenting time, specify why more frequent parenting time would be harmful to the child and what parent must do to achieve at least weekly parenting time. b. If parent is limiting parenting time, indicate parents reasons for wanting less frequent parenting time and project if and when frequency could be increased. 3. Specify behaviorally specific activity expected of the parents during parenting time.  MACROBUTTON [b2] "Click Here and Type"  The development of this plan was negotiated with (also list those individuals who were unavailable to participate in the development and why not): Indicate who the plan was negotiated with and any individual who is involved in the plan but was unavailable to participate in its development. If any individual was unavailable, state the reason why they were not involved. If the parents were not involved in developing the case plan, the reason why must be documented. (See CFF 722-6, Parental Involvement in Developing the Plan.) Youth age 14 and older must be involved in the development of the plan and be responsible for its implementation with the assistance of identified individuals.   MACROBUTTON [b2] "Click Here and Type"  By signing below I agree that I have read the above, discussed it with my foster care worker, and understand what is expected of me to facilitate the permanency planning goal. Upon clicking in the Name field below, a question box allows addition of signature lines for Youth Age 14 and Older, if applicable and/or additional Parent / Caretaker signature rows. Parent/Caretaker Name:  FORMTEXT        Parent/Caretaker Signature:  Date:  FORMTEXT      By signing below on behalf of the Department of Human Services we agree to those activities outlined above and will assist the family in their efforts to facilitate the Permanency Planning goal. Upon clicking in the Name field below, a question box allows signatures lines to be added as necessary that will include at least the foster care worker and supervisor. 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The Purchase of Service (POS) agency is responsible for all elements of the service plan in cases where they have accepted responsibility for providing family services per the DHS-3600 (RFF-3600) contract. The local office is responsible for reporting requirements only when the POS agency has not accepted total case responsibility. The report from the local office should not duplicate the POS agency report, but should address those areas for which the POS agency is not responsible per the DHS-3600 contract. Signing the ISP submitted by the POS agency indicates approval. The approved ISP is to be returned to the POS agency within seven days of receipt; a copy is retained in the childs case record. The local office is responsible for knowing what services are being purchased from the POS agency and for monitoring compliance with the DHS-3600. When a noncompliance situation is identified, it is to be brought to the attention of the POS agency both verbally and in writing. If efforts to resolve the area of conflict locally are not successful, the situation is to be brought to the attention of the appropriate Zone Office. If the Zone Office is unable to intervene successfully, then the Division of Child and Family Services is to be involved. (See CFF 914, Monitoring Worker Responsibilities for more information.) Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.AUTHORITY: P.A. 280 of 1939. RESPONSE: Voluntary. PENALTY: None DHS67 (Rev. 8-07) Previous edition obsolete. MSWord  PAGE 1  FILENAME \* MERGEFORMAT 0067.dot DHS67 (Rev. 8-07) Previous edition obsolete. MSWord  PAGE 2  FILENAME \* MERGEFORMAT 0067.dot 5/0vw)j)v:$If5gdg8gdg8:kdsA$$Ifl4|))4 laf4 $Ifgdg8 l|| $If^ $If^ $$Ifa$ckdA$$Ifl4h|))04 laf4|}~"we__$If( !(:]gd:{q( !(:]gd:{qskddB$$Iflh0|)d04 la RSTUVWqrz{~ "$&:<>HJRThjlnxz|~ ҕҕjEh5UjDh5Uh55CJOJQJjh5UmHnHujCh5Ujh5Uh5h55@CJOJQJh5CJOJQJhPPKhc hc0J7hc0J7mHnHujhc0J7U2#&P0= /!"#$% &P/ =!"`#$%& 00&P/ =!"`#$%# 0&P/ =!"`#$%& 00&P/ =!"`#$%# 0&P/ =!"`#$%& 00&P/ =!"`#$%# 0&P/ =!"`#$%& 00&P/ =!"`#$%# 0&P/ =!"`#$%& 00&P/ =!"`#$%# 0&P/ =!"`#$%& 00&P/ =!"`#$%# 0&P/ =!"`#$%# 0&P/ =!"`#$%# 0&P/ =!"`#$%& 00&P/ =!"`#$%DFCCaseNoEnter Foster Care Case Number CaseInfo.MAIN$$If !vh55 5#v#v #v:V l4N9,55 5/  / / /  4a D FCCaseNameEnter Foster Care Case Name$$If !vh55 5#v#v #v:V l4N9,55 5/  / / /  4a DFCWorkerLoadNo(Enter FIA Foster Care Worker Load Number$$If !vh55 5#v#v #v:V l44N9,55 5/ / / / /  4a f4D FCWorkerName!Enter FIA Foster Care Worker Name$$If !vh5555 5#v#v#v#v #v:V l4N95555 5/ / / /  4a DPSCaseNo%Enter Protective Services Case Number$$If !vh5555 5#v#v#v#v #v:V l4N95555 5/ / / /  4a D PSCaseName#Enter Protective Services Case Name$$If !vh5555 5#v#v#v#v #v:V l4N95555 5/ / / /  4a D DateCompletedEnter Date CompletedDCourtNoEnter Court ID Number$$If !vh5555 5#v#v#v#v #v:V l4N95555 5/ / / /  4a DeCheck1Check if Initial Service PlanDPOSA&Enter Purchase of Services Agency Name$$If !vh5555 5#v#v#v#v #v:V l4N95555 5/ / / / 4a DeCheck2Check if Updated Service PlanDPOSW-Enter Purchase of Services Agency Worker Name$$If !vh5555 5#v#v#v#v #v:V lN95555 5/ / / /  4a L$$If !vh5N9#vN9:V lN95N94a L$$If !vh5N9#vN9:V lN95N94a L$$If !vh5N9#vN9:V lN95N94a $$If !vh55:5:55T5#v#v:#v#vT#v:V lN955:55T5/ / / / /  / / 4a D fiacasenoFIA Case Number ChildInfoAutoD&Text7Enter Child NameDf Dropdown3$Select Permanency Planning Goal Code ReunificationAdoption GuardianshipPerm Placement With Relative(Plcmnt In Another Planned Living ArrangeD Text9Enter Target DatepDf Dropdown5xSelect Anticipated Next Placement Type: Foster Home, Relative, Residential, Adoptive Home, Own Home, Ind. 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ServiceRefDfMedical/Physical HealthMental Health and Well-BeingChild Development&Fam and Unrel Caregiver Rel/Attachment EducationSubstance Abuse Sexual Abuse Life SkillsPeer/Adult Social RelationshipsCultural/Comm IndentIndependent LivingEmot StabilityParenting Skills Subst. AbuseDom. RelationsSoc. Supp. Sys.Comm./Interper. SkillsLiteracy Intell. Cap. EmploymentPhy. Health. Iss.Res. 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