ࡱ> y irbjbj .{{yOB,,#####Z(Z(Z(XB~VtZ(eD/033334s6/7`Ta#b#b#b#b#b#b$VgjGb#84488Gb##33d4A4A4A8F#3#3Ta4A8Ta4A4AU X3g}$9ZW<@ad0eXj~:pjxXj#XT707"4A77777GbGb=F777e8888j777777777, L": CHILDREN S FOSTER CAREDHS FC Worker Load #: FORMTEXT      INITIAL SERVICE PLANDHS FC Worker Name: FORMTEXT      Michigan Department of Human ServicesPAFC Agency Name: FORMTEXT      PAFC Agency Worker Name: FORMTEXT      County of Referral: FORMTEXT      Court Jurisdiction: FORMTEXT      Court Docket #: FORMTEXT      Date Completed: FORMTEXT      Report Date: FORMTEXT      Report Period Begin Date: FORMTEXT      End Date: FORMTEXT      IDENTIFYING INFORMATIONChild(ren): (List separately) name, date of birth, case number, date entered care, current placement type (if relative care, name and address of relative; if institution, name and address of institution; if foster home, note foster home placement only), date entered current placement, permanency planning goal and concurrent permanency goal. Specify if the child(ren) is Native American and tribal affiliation, if applicable.  MACROBUTTON [1] Add Child(ren) Below  To insert additional names, copy and paste below Native American row.NameDate of BirthLog NumberCase NumberChild GenderChild RaceHeightWeightHair ColorEye ColorReligionDated Entered CareDate of Current PlacementCurrent Placement TypeAnticipated Next PlacementDate of Anticipated Next PlacementCurrent Legal StatusFederal Permanency Plan GoalConcurrent Federal GoalChilds Address (if not FH)Native American?If Yes, Tribal AffiliationDate Caregiver and Child Provided Notice of HearingInsert copied rows here Document in social work contacts date Native American question asked, to whom, and outcome. Parent (Caretaker) Name(s): Name and relationship to child, date of birth, address/phone (if multiple children are included in this service plan, the names of each mother and father should be listed; name of father or mother should be listed even if whereabouts are unknown). Include any non-parent adults involved in the household that the court may order to participate in the service plan or who will be involved in the service planning. A household contains biological or legal parents. If there is a step-parent that person must be in the household. These households must be designated as participating or non-participating. Indicate Yes or No if the parent is participating in service planning, cant locate/unavailable, deceased, signed APPLA/APPLA-E agreement in place, parental rights terminated, refused, reunification services not need/per count order, or unwilling. Definitions: Cant locate / Unavailable Worker has completed a diligent search for parent(s) with legal right to the child(ren) through such things as Secretary of State inquiry, search of telephone books, US Post Office address search, follow up on leads provided by friends and relatives, legal publication, etc. and has been unable to locate. The parent(s) has refused to respond to mailings from the worker. If there is no legal father, attempts should be made by the worker to identify and locate the putative father in order to establish paternity. (See FOM 722-6, Efforts to Identify and Locate Absent/Putative Parent(s) for more information.) Deceased Is used when the parent is deceased. Not an Assessment Household There is no legal, biological, or putative parent in the household. Another Planned Permanent Living Arrangement (APPLA/APPLA-E) For youth 14 and older with an APPLA Agreement accepted by the court (FOM 722-7) For youth 16 and older with an APPLA-E Agreement accepted by the court (FOM 722-7) Parental Rights Terminated Is used when parental rights have been terminated. Refused The parent has indicated in writing to the court that he/she does not intend to participate in reunification. Reunification Services not Needed/Per Court Order The court has determined that reunification services no longer need to be offered to the parent. Document court determination that reunification services no longer need to be offered in the reasonable efforts section of the service plan. Unwilling Worker has attempted to engage parent(s) with legal rights to the child(ren) in reunification services through scheduled appointments in the office, in the parents residence, or at a location designated by the parent at least once a month in a six month period as documented in the case file.   MACROBUTTON [1] Add additional parents below  To insert additional names, copy and paste rows below Protective Services Risk Level.NameRelationshipChildrenParticipatingParents Current Address:Date of BirthTelephone:Protective Services Risk Level:Insert copied rows here I.LEGAL STATUSThe petition is included in the legal section of the case file and is not repeated in the Legal Status of this file. Summarize the allegations and the disposition in the  Reason Child(ren) entered care section of this report.A.Reason child(ren) entered care l Describe the event or incident that led to the removal and placement of the child(ren). l Are there prior CPS referrals, investigations, services and / or placement for this family? If yes, then describe. l If any child(ren) remain in the family home, indicate the reasons why the child(ren) remaining in the home are safe and what services are being provided to ensure continued safety.   MACROBUTTON [1] Click Here and Type  B.Court History Child(ren): (List separately) name, petition date, petition type, hearing date, hearing outcome, order date, order type, requirements of the court through its order.  MACROBUTTON [1] Click Here and Type  C.Next Court Date  MACROBUTTON [1] Click Here and Type  II.Reasonable EffortsNote:For children who may be Indian Children, see NAA 205, Active Efforts. For all other children, see FOM 722-6, Reasonable Efforts. Information from CPS transfer.A.Include services that were provided to the child(ren) and parent(s) to prevent removal.   MACROBUTTON [1] Click Here and Type  B.If services were not provided, were not required or if providing services to the family was not reasonable, explain why.   MACROBUTTON [1] Click Here and Type  C.Likely harm to the child(ren) if he/she were to be separated from parents, guardian, or custodian?   MACROBUTTON [1] Click Here and Type  Likely harm to the child(ren) if he/she were to be returned to parents, guardian, or custodian?   MACROBUTTON [1]  Click Here and Type  III.Social Work Contacts l List date, person(s) contacted, role/position, type of contact (telephone, in person, home visit, parenting time, worker/supervisor consultation, office visit, FTM/PPCS, etc.) and contact location (foster home, court, school, etc.) for each contact, attempted contact and scheduled but unkept appointment. l Document date Foster Parent/Relative Caregiver/Child provided notice of court hearing. l Provide a brief narrative of topics covered during the contact. Limit the narrative to 2-3 sentences. l For face-to-face contacts with foster children, include a statement whether the foster care worker had a private meeting with the child(ren), viewed the child(ren) s sleeping arrangements and had a conversation with the caregiver regarding safe sleep requirements in applicable cases. l The following face-to-face contacts must be documented in social work contacts, regardless of whether the primary foster care worker was part of the contact: ll Parent/assigned foster care worker contacts ll Child/assigned foster care worker contacts ll Caregiver/assigned foster care worker contacts ll Home Visits ll Parenting Time ll Family Team Meetings/Permanency Planning Conferences ll Sibling visits, if applicable See FOM 722-9, Updated Service Plan for required face-to-face contacts. See FOM 722-8, Initial Service Plan for required face-to-face contacts and required narrative.   MACROBUTTON [1]  Click Here and Type  IV.Assessment Please complete each section for every household.A.Family Social History and Assessment 1.Family History l Describe the family of origin for all caretakers and non-parent adults who are involved in the case. l Is there a history of child abuse or neglect and/or placement for the caretaker(s)? l How does the caretaker s history impact his or her own parenting skills and the current situation? l Describe other relevant information about the adult members of the household, including any significant health issues, criminal history, intra-familial relationships. l Briefly summarize the adult (s) interaction with child(ren) and with each other, if applicable. l Describe the willingness and capacity of the adult(s) to change the situation that brought the child(ren) into foster care.   MACROBUTTON [1]  Click Here and Type  2.Family Self Assessment l What is family s reaction to the event / removal and the agency s definition of the problem? l What is the family s definition of the problem? l What is the family s assessment of their functioning? l What does the family think would make things better? l What resources does the family believe will help meet goals?   MACROBUTTON [1]  Click Here and Type  3.Family Resources l Identify the relative network resources currently provided or available potential resources, and the resources from the surrounding community. l Include an assessment of family s feelings of support from the relative network.   MACROBUTTON [1]  Click Here and Type  4.Religious Affiliation (if applicable) l What is the religious affiliation of the parent(s) and child(ren)? l What is the family s history of participation? l What are the participation and attendance requirements? l Explain any special dietary requirements, grooming, dress or make-up requirements for the child(ren) in placement.   MACROBUTTON [1]  Click Here and Type  5.Family Assessment of Needs and Strengths l Address and explain each individual item scored as a need on the Family Assessment of Needs and Strengths for each caretaker and household. Please attach a DHS-146. l Identify the needs that (provide specific and concise examples) are primary barriers to reunification and any substance abuse needs. l Indicate how the primary barriers are related to the reasons the child(ren) entered care, and l The priority for treatment services during the ISP planning period. l Address and explain each individual item scored as a strength on the Family Assessment of Needs and Strengths for each caretaker and household. ll List and describe strengths in the family not identified on the assessment but that are present in the family. l Describe all other relevant information about the caretakers and non-parent adults, including: ll Observations on intrafamilial relationships and participants in the case, and ll The results of the Central Registry and criminal history checks, if available.   MACROBUTTON [1] Click Here and Type  B.Child Social History and Assessment The foster care worker must request information from the child(ren)s family, foster family, the child (when appropriate) service providers, and any other professionals familiar with the child prior to completing the child(ren)s needs and strengths assessment and social history. Complete this section after the age appropriate DHS-432, 433, 434, 435, Child Assessment of Needs and Strengths, is completed; see FOM 722-8B, Child Assessment Requirements. 1.Placements during the report period.l Describe, for each child(ren) (list separately): name, living arrangement, begin date, end date, reason for replacement, efforts made to prevent a replacement, and describe all prior formal and informal placements.  MACROBUTTON [1]  Click Here and Type  l For Indian children, include Foster Care Placement Preference, NAA 215, Placement Priorities for Indian Children.2.Provision For Medical, Dental and Mental Health Services MEDICAL For each child complete the following: l Child name l Current health status and medical needs at time of entry into foster care. l List prescribed medications and regularly dispensed over-the-counter medications, including dosage, diagnosis resulting in prescribed medications and prescribing physician. l Documentation of informed consent for each psychotropic medication. l Any needed emergency medical, dental and health care provided since entry into foster care. l Date of last full medical examination. l Description of any needed medical follow-up appointments. l Immunization status (refer to immunization chart in FOM 801). l Child s perception of their medical needs, if applicable.  MACROBUTTON [1]  Click Here and Type  DENTAL For each child complete the following: l Child name l Date of dental examination or date of scheduled appointment. l Description of any needed dental follow-up appointments. l Child s perception of their dental needs, if applicable.  MACROBUTTON [1]  Click Here and Type  MENTAL HEALTH For each child complete the following: l Child name l Date of referral to mental health provider for mental health screening and/or assessment. (From the 30 day medical/physical exam.) l Description of any needed mental health treatment/assessment, if applicable. Include name of treatment provider, frequency of sessions and treatment goals. l Child s perception of their mental health needs, if applicable.  MACROBUTTON [1]  Click Here and Type  3.Child(ren) s Current StatusDescribe, for each child under court jurisdiction, current status of child including: l A physical description including distinctive characteristics. l Emotional and physical development. l Past experiences, and concerns. l Participation in extracurricular/cultural/hobbies, likes and dislikes, etc. l Relationships with siblings, if applicable. l Describe all prior formal and informal placements. l How the child s permanency plan was shared with the child and the child s feelings about the plan. l Justification for DOC, including foster parent/caregiver activities during report period.   MACROBUTTON [1]  Click Here and Type  4.Educational Information For each child, complete the following information: l Child name. l Name of the school child was attending at time of removal. l Grade. l Special education information, if applicable. l Detailed narrative of the child s academic performance and behaviors in school. Describe all services provided by school, foster parent, etc. to meet the child s specific identified educational needs. Include progress updates. l For foster parents receiving a Determination of Care (DOC) supplement based on providing activities for education participation, detail the specifics for school collaboration and the actual tasks involved in the daily educational interventions required for the child in the case service plan. l Statement documenting child/youth is attending elementary or secondary school as a full-time student, has completed secondary education or is incapable of attending school on a full-time basis due to medical condition. Documentation of child/youths medical condition (from a medical provider) must be on the case plan and updated quarterly If a replacement occurred during this report period, the following additional information is required: l Name of the school child was attending prior to change in placement. l The appropriateness of the current education setting and the proximity to the school where the child was enrolled prior to the replacement. l Determination of the preferred school for the child based on best interest factors and the input of the parent or legal guardian, along with the education liaison. (See FOM 722-6.) l School transportation plan (include role of the school and foster parent, if applicable). l Date child began attending school. Full-time school attendance is required within five days of replacement. If child did not start school within five days give explanation. l Verification from new school child s previous school record was obtained within 30 days.  MACROBUTTON [1] Click Here and Type  5.Child(ren)s Reaction to PlacementDescribe, for each child under court jurisdiction, their reaction to: the abuse and/or neglect that led to placement. the placement out of the family home. (Separate from the family reaction), and the services the child feels would benefit his/her family. Childs feelings and observations about current placement.   MACROBUTTON [1] Click Here and Type  6.Child Needs and Strengths AssessmentIndicate for each child under court jurisdiction. Address and explain each individual item scored as a strength or need on the Child Assessment of Needs and Strengths. Please attach the appropriate DHS-432, 433, 434 and/or 435. l Identify and describe the priority needs of the child(ren) for service. Provide specific and concise examples to support narrative. Priority needs are defined as those domains scored with the highest negative point value that is not a situational concern. l Identify and explain the situational concerns, which cannot be identified in consecutive report periods. Situational concern is defined as an issue identified for a child that is short term and may be in response to a recent event or change in placement or in the childs family. Situated concerns must not be identified as a need. Identify other needs that are any domains that have a negative score that are not considered priority or situated concerns. l List and describe all strengths of the child whether identified on the assessment or not. Strengths are defined as any domain scored with a 0 or positive number. l Document child s view of need and strength if developmentally age appropriate.  MACROBUTTON [1]  Click Here and Type   MACROBUTTON [1]  Add additional child(ren) below To insert additional child(ren), copy and paste below 7.a.7.Placement Informationa.Placement Selection Criteria Child Name:  FORMTEXT      Rank each from 1 4; 1 being the reason(s) most important to the placement decision, 3 the least important and 4 not applicable.The case plan which includes the goal of permanence.The physical, emotional, educational and safety needs of the child(ren).Proximity to the child(ren)s family.Placement within relative family network of the child(ren).Placement with siblings of the child(ren).The child(ren)s and child(ren)s familys religious preference.The least restrictive, i.e., most family like setting.The continuity of relationships.Availability of placement resources for the purposes of timely placements.Expressed preferences for placement by the foster child.Appropriateness of the childs current educational setting and the proximity to the school child is enrolled at time of removal.Insert copied rows here b.If any Placement Selection Criteria are not met, explain why not.  MACROBUTTON [1] Click Here and Type  c.For Indian Children, include the Foster Care Placement Preference from NAA 215, Placement Priorities For Indian Children.  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CJOJQJ^JaJphf)hb05<B* CJOJQJ^JaJphfhBzCJOJQJ hlhBzhlhBzCJOJQJh~ CJOJQJ hlh~ hlh~ CJOJQJ+,-./\yn ($IfgdBz $Ifgd~ $Ifvkdg1$$Ifl4\ N * +4 laf4ytBz\]uvwxy}?}=kd2$$Ifl4*++4 laf4ytb0$Ifgdb0vkd1$$Ifl4\ N * +4 laf4ytBzy|Ԁss $$Ifa$gd~ $Ifgd~  ]^ ckd2$$Ifl4FT *@ +    4 laf4ytb0 $$Ifa$ ҀԀր؀ڀ&(*,.0468:bh뚏l\h7c<B* CJOJQJphf(h]Uh7c<B* CJ OJQJaJ phfhlh55CJOJQJhv 5CJOJQJhlh5CJOJQJ hlhGhlhHB*ph hlhHjhlhHU hlh~ hlh~ 5CJOJQJh~ 5CJOJQJhlh~ CJOJQJh~ hԀր؀,.024:bdyyyyp $$Ifa$$If  ]^ gd~ ]^gd~ ckd53$$Ifl4FT *@     4 laf4yt~ dfhn $$Ifa$$Ifnkd3$$Ifl4\D*"4 laf4.V|||$ r$If^`ra$gd7c $$Ifa$$If[kd3$$Ifl4FT *@     4 laf4*@Rb؎*,.02<>DFT˻p]M:$hyh<B* CJOJQJphfh<B* CJOJQJphf$hyhm<B* CJOJQJphf(h]Uh7c<B* CJ OJQJaJ phfh7c<B* CJOJQJphf$hyh~<B* CJOJQJphf$hyhy?J<B* CJOJQJphfh~ <B* CJOJQJphfhA<B* CJOJQJphfUh-3<B* CJOJQJphf$hyh5<B* CJOJQJphfthe same out of home placement, describe ongoing efforts to place siblings together and provide an explanation of the reasons for the split placement. l Note: If siblings are split, second line supervisory approval is required. The second line supervisor must sign the ISP in the Signature Section. l If there are no siblings or if siblings are placed together, write N/A.   MACROBUTTON [1]  Click Here and Type  b.Sibling and Relative VisitationDocument all siblings and relative visits. Visits between siblings are to occur at least monthly, if in separate placements. Specifically document the following: l Dates of visits or contacts. l Location of visits or contacts. l Duration of visits or contacts. l Other ongoing interactions between siblings (phone calls, letters, school activities, etc). l Worker assessment on the quality of sibling visitation, based on personal observations, each child s description of visits and any reports from others, including parent(s), relative(s) and foster parent (as applicable) l Include a discussion of any exceptions (missed appointments, changed appointments, suspension of appointments and changes in supervision status) to the plan during the reporting period. l Discuss any visitation arrangements for relatives. l Describe any safety concerns and specify how they were addressed.   MACROBUTTON [1]  Click Here and Type  Sibling placement/visitation is contrary to the children s safety or wellbeing due to:.  FORMCHECKBOX N/A children placed together FORMCHECKBOX The visit may be harmful to one or more of the siblings FORMCHECKBOX The sibling is placed out of state in compliance with the Interstate Compact on Placement of Children.  FORMCHECKBOX The distance between the children s placement is more than 50 miles and the child is placed with a relative. FORMCHECKBOX One of the siblings is above the age 16 and refuses such visits, including reasons for refusal. FORMCHECKBOX Other. (If other, provide explanation in summary below.)  MACROBUTTON [1]  Click Here and Type  c.Relative Notification, Resources and Placementl A statement of the efforts that were made to place the child with the family or with the Relative Network. l Describe how identified relative are involved in the case planning process. l Document ongoing relative engagement efforts, and follow up activities with identified relatives. l Identify any relative resources (in Michigan and other states per Interstate Compact for Placement of Children  ICPC - procedures) with the potential to provide placement or other supports for the child as indicated by the Relative Response, DHS-989. l List all relatives who were notified of the child(ren) s placement via Relative Notification Letter, DHS-990. l If a decision has been made regarding relative care placement of the child, include the decision and the rationale for the decision or attach a copy of the DHS-31, Foster Care Placement Decision Notice to this USP. l If the relative is pursuing foster care licensing, document progress made toward achieving licensure. l If licensing waiver is being pursued, document reasons why and approval/denial date.   MACROBUTTON [1]  Click Here and Type  d.Best Interests of Current Placementl Describe the foster parent/relative caregiver s willingness and capacity to meet the specified needs of the child. l Describe why the current placement is in the child s best interest. l Describe how this specific placement supports the child s permanency plan. l Document any CPS complaints regarding the caregiver omitting any information about the CPS referral source. l Document any foster home licensing complaint investigations regarding caregiver during this report period and any corrective action plans that were a result of the complaint. l Describe any safety concerns in the home and specify how it will be addressed.   MACROBUTTON [1]  Click Here and Type  9.Residential CareDescribe reasons for residential placement. If the youth is 10 years of age or over and is placed in a residential or institutional setting: l Document whether Wraparound, assisted care or other efforts were made to prevent the residential placement. Include the date of FTM or other efforts that were made. l Identify the plan for services that will allow the youth to be placed in a less restrictive setting. OR If the youth is under age 10 and is placed in a residential or institutional setting: l Document whether Wraparound, assisted care or other efforts were made to prevent the residential placement. Document that a screening for Fetal Alcohol Spectrum Disorder was completed. l Identify the plan for services that will allow the youth to be placed in a less restrictive setting. l If there were no services provided, explain why not If the youth is not placed in a residential or institutional setting, write N/A in the space provided.   MACROBUTTON [1]  Click Here and Type  C.Foster Parent/Relative Caregiver Input l Attach written input from the caregiver(s) about the child(ren). If a written statement is not available, summarize the caregiver(s) feedback. See FOM 722-6 Foster Parent/Relative Caregiver Input. l Document date the child s Medicaid card, Medicaid number and Consent for Emergency Treatment card (DHS-3762) was given to caregiver. l Describe the caregiver family s adjustment to the child s placement. l Document how the permanency plan for the child was shared with the caregiver and the caregiver s comments regarding the permanency plan. l Document how the caregiver involves the parents in decision making regarding the child(ren) s needs and activities. l Describe efforts to engage the caregiver in case planning.   MACROBUTTON [1]  Click Here and Type  D.Progress to Date l Describe any changes in the family since the child(ren) entered care. (Provide specific and concise examples.) l Record all referrals made for the family since placement including any services provided by the Agency at the time of placement in the Service Referral Table of the Parent-Agency Treatment Plan and Service Agreement. l Provide a narrative of all PCCs/FTMs held this report period including the outcomes for each meeting. l Specify efforts to identify and locate absent parents. l Describe any safety concerns and how they were addressed.   MACROBUTTON [1]  Click Here and Type  *Please see the attached Parent-Agency Treatment Plan and Service Agreement. V.Recommendation to Court (Complete for each child) A.Should Child(ren) Remain in Out of Home Placement? l For each child under court jurisdiction, for the period covered by this report, identify case action as continued placement, return home and monitoring, or closure. l If the child(ren) should remain in out-of-home placement, describe why it is not in the child(ren) s best interest to be returned home, placed for adoption, or placed within the relative network.   MACROBUTTON [1]  Click Here and Type  B.Mandatory Petition for Termination of Parental RightsIf a mandatory petition for termination of parental rights has been filed requesting termination of parental rights at the dispositional hearing, the recommendations should contain either:1.A statement that the agency believes it is in the child(ren) s best interest to terminate the parents rights to the child(ren) and the reasons why; or2.Documentation regarding the compelling reasons why termination of parental rights is not in the child(ren) s best interest.If the Mandatory Petition section is the same for all children, check yes and the appropriate recommendation below. If this section is different for one or more children in the family, check no. Then click in the Child Name section and follow directions to add a section for each child for which the recommendation is different.This recommendation applies to all children: FORMCHECKBOX Yes FORMCHECKBOX No  MACROBUTTON [1]  Add additional Recommendations below  To insert additional Recommendations, copy all rows (including  Click Here and Type section) and paste below. Place an X after a through g if appropriate.Recommendation for: FORMTEXT       Enter the child s name.Place an X in only one box (1  3) and as many a  I as necessary if X is placed in 3.1.A mandatory petition is not required. If #1 is checked, a petition for termination for parental rights has not been filed. Write N/A in the space below.2.A petition for termination of parental rights has been filed and it is in the child(rens) best interest to proceed. If #2 has been checked and it is in the best interests of the child to proceed, provide the reasons why in the space below. 3.A petition for termination of parental rights has been filed and it is not in the child(rens) best interest to proceed. Indicate why termination is not in the best interests of the child by checking as many boxes as apply below:a.Adoption is not an appropriate permanency plan.b.The child is being cared for by a relative.c.No grounds to file a termination petition exists.d.There are international legal obligations or compelling foreign policy reasons that preclude termination of parental rights.e.The supervising agency has not yet provided the services detailed in the prior service plans to make reunification possible.f.Child is an unaccompanied refugee minor.g.Other. Explain below. If this is the compelling reason, there must be clear documentation within the case service plan of the individual circumstances of the child that necessitates this selection.  MACROBUTTON [1]  Click Here and Type  Insert copied rows here C.Recommended Court Orders In this section, write any court orders requested for parental or caretaker compliance with the service plan. If applicable, request that non-parent adults participate and comply with the service plan.   MACROBUTTON [1]  Click Here and Type  Report Date: REF Date2  Report Period Begin Date: REF BeginDate  End Date: REF EndDate  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. Split Sibling Placements require approval signature of a second line supervisor.  Name and Title: FORMTEXT       Signature: Date:  FORMTEXT       Name and Title: FORMTEXT       Signature: Date:  FORMTEXT       Name and Title: FORMTEXT       Signature: Date:  FORMTEXT       Name and Title: FORMTEXT       Signature: Date:  FORMTEXT       DHS Local Office Name: FORMTEXT        DHS Local Office Approval: Name and Title: FORMTEXT       Signature: Date:  FORMTEXT      Distribution of Case Plan  MACROBUTTON [2]  Click Here and Type  Use this field to indicate who typed the report, the date typed, etc., as necessary.  FORMTEXT       Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, 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     DHS-65 (Rev. 9-12) Previous edition obsolete. 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