ࡱ> ~}5@ 6"Tbjbj22 XX * d,---pl-q,c?h-////0v?1L1(;>>>>>>$@RC>i10011>//?2221//;21;2R2)36\6/ r SH-1:(6b7|3?0c?06,C2C\6,,Cj611211111>>,,2,,ADOPTIVE FAMILY ASSESSMENT ADDENDUMMichigan Department of Human Services  MACROBUTTON [1] "Click here to enter agency name and address"  Father s Name:Home Phone Number: FORMTEXT       FORMTEXT      Mother s Name:Work Phone Number: FORMTEXT       FORMTEXT      Address:Cell Phone Number: FORMTEXT       FORMTEXT      Adoption Worker:Agency:Report Date: FORMTEXT       FORMTEXT       FORMTEXT       DATES OF CONTACTDatesWith whom (include role/position)Type and reason MACROBUTTON [1] "Click here and type"  Current Household Members: FORMTEXT      Any Changes In Living Arrangements Or Financial Status: FORMTEXT      Current Health Report (include any new physical or mental conditions): FORMTEXT      Current References (within12 months or if family has adopted a child since last assessment): Summarize the personal references (DHS-608) received. FORMTEXT      Current Record Clearances: FORMTEXT      Other Significant Factors: Include protective services complaints and referrals FORMTEXT      Type of Child Desired: FORMTEXT      If there is an identified child/children for this adoptive family, complete the following questions:1. What are the applicant s expectations of adoption? FORMTEXT      2. What are the extended families attitudes toward adoption? FORMTEXT      3. What are the family s plans to discuss adoption with the adopted child(ren)? FORMTEXT      4. How will the applicant(s) assist the child(ren) in maintaining relationships with siblings or other significant persons (if appropriate)? FORMTEXT      5. For relative adoptions: How has the prospective adoptive family demonstrated the willingness and ability to keep the child safe from continuing physical or emotional harm from the birth parents? FORMTEXT      6. If the number of children who are currently in the home, or will be placed in the home for adoption: is four or more, or wiFJ   " $ B L j l    xtphjh,UhahKbj hLDUhLDjhLDUjhf_UmHnHujh"zUh"zjh"zUh$`h,h~th1%hmxh1%5h~th~t5B*ph h~t5jh~t5Uh+ ` h+ `5 h(36h(36h(36hY(HJ skfZ !$$Ifa$gdmxgd+ `!$a$gdmx<kd^$$Ifl4z,z,4 lalf4 $Ifgd(36<kd$$Ifl4z,z,4 lalf4 $Ifgd(36S TB " $ B h j I ^jaa $Ifgd$`Lkd$$Ifl0X z,X " 4 lal $Ifgdaq<kd$$Ifl4z,z,4 lalf4  * R QHH $Ifgd$`Xkd$$Ifl0X z,X " 4 lalp $IfgdaqLkd$$Ifl 0X z,X " 4 lal   & ( * , @ B D N P R T d f p   2 4 H J L V X Z \ p r t ~ ھںڲ޲ΘںތvjHh$`Ujh$`Ujh$`Uhajh BUj|h+ `Uh+ `jh+ `Uh$` h,5jh BUhUPjhUPUh,jhf_UmHnHujh,Ujh,U.R T f QHH $Ifgd$`Lkd$$Ifl0X z,X " 4 lal $IfgdaqXkdm$$Ifl 0X z,X " 4 lalp   0 o^I ^9kd$$Iflz,z,4 lal $IfgdaqLkdd$$Ifl 0X z,X " 4 lal0 2 Z 6_kd2 $$Ifl FX z,"     4 lal $Ifgd$`_kd@$$Ifl FX z,"     4 lal~ D F h p r ŻűŐ|qڀ|fڀj h"zUj h"zUh"zjh"zUhe?uh~t hmx5hYB5B*phh~thYB5B*ph hYB5jhYB5Uh\hmx56hmxh`!:h$`CJ KH \^JaJ jhf_UmHnHujh$`Uh$`jh$`U' " B D Nbkd3 $$If94F z,      4 9a9f4 $Ifgdyw9kd $$If9z,z,4 9a9 #$IfgdywD tk $Ifgde?u9kdm $$Iflz,z,4 lal $Ifgdaqgdaq9kd $$If9z,z,4 9a9 !$Ifgdyw n p (y?9kdw $$Ifl z,z,4 lal $Ifgde?u9kd $$Iflz,z,4 lal $Ifgdaq9kdG $$Ifl z,z,4 lal *,@BDNPTbxz xz|~<>~sjh BUhYBhe?uB*ph3fhYBhYB<B* phfhYBjh BUh+ `jmh BUhmxhe?u<B* phfhmx<B* phfhmxhjhf_UmHnHuj=h BUhUPjhUPUhe?uhbO -(*RTz|y?9kd$$Iflz,z,4 lal $Ifgdaq9kd$$Ifl z,z,4 lal $Ifgde?u9kd $$Iflz,z,4 laly?9kd$$Ifl z,z,4 lal $Ifgde?u9kd7$$Iflz,z,4 lal $Ifgdaq9kd$$Ifl z,z,4 lal,y?9kd$$Iflz,z,4 lal $Ifgdaq9kd7$$Ifl z,z,4 lal $Ifgde?u9kdg$$Iflz,z,4 lal(*.P\hj~&(*46:"$8:<FHL\p᪢颪᪈hywj#hUPUjhmxUjhmxUhmxjhUPUjhUPUhhUP5\hhUP5jh BUhUPhe?ujhf_UmHnHujhUPU2,.fhH? $Ifgd B9kd-$$Ifl z,z,4 lal9kd$$Ifl z,z,4 lal $IfgdUP9kdg$$Ifl z,z,4 lal8:y?6 $Ifgdyw9kd-$$Ifl z,z,4 lal $Ifgd B9kd]$$Ifl z,z,4 lal $Ifgd B9kd$$Ifl z,z,4 lal "Jy?6 $Ifgd B9kd$$Ifl z,z,4 lal $Ifgd B9kd]$$Ifl z,z,4 lal $Ifgdyw9kd$$Ifl z,z,4 lalJLy?9kd$$Ifl z,z,4 lal $Ifgdyw9kd$$Ifl z,z,4 lal $Ifgdyw9kd$$Ifl z,z,4 lalHIIIIIIIIIIIJJJJJJJdKKKKKKKKKKLLLLLLLLLLMMMֽڹڹڹڵڹީֵ֓ҋjh BUjhUPUjhbO UjhbO UhbO hywhe/EjhUPUjhUPUUh BhUPhmxjhf_UmHnHujhmxUjShmxU3HIIIII+F+^P9kd$$Ifl z,z,4 lal $Ifgd B9kd$$Ifl z,z,4 lal<$If^gd B & F 8t($If^t`(gd B <$IfgdUPll result in more than three children under the age of 3 in the home, or will result in a total of 6 or more children in the home, document the family s ability to care for a large sibling group (see CFA 510 for requirements). FORMTEXT      7. What are the alternate care plans for the permanent care of the child(ren)? Include more extensive details if the applicant(s) age and/or health status are assessed to be a concern. (See CFA 510 for requirements.) FORMTEXT      8. If applicable, summarize the professional references (DHS-610) received for the adoptive family. FORMTEXT      9. If applicable, summarize any Adult Child References (DHS-611) received for the adoptive family. FORMTEXT      10. The following specific child(ren) are identified for adoption by the adoptive family: FORMTEXT      11. The following training or support needs have been identified for the adoptive family: FORMTEXT      Recommendation: FORMTEXT      Adoption Worker Signature:DateAdoption Supervisor Signature:DateDepartment 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. 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