ࡱ> 14./0 @ "bjbj "* !$\(>(̳,*ȓȓȓ[lǘi$$RJȓȓLȓȓiiȓ" pJ˙0̳(_(((()((d@O?(((OJUVENILE GUARDIANSHIP HOME STUDY (NOT REQUESTING GUARDIANSHIP ASSISTANCE)Case :# FORMTEXT      Case Name: FORMTEXT        FORMTEXT      Worker Load #: FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT   Worker Name: FORMTEXT      Michigan Department of Human ServicesAgency Name: FORMTEXT      Agency Address: FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Date Child(ren) Entered Care: FORMTEXT      Child Name(s) and Age(s): FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      1.Name(s) of prospective guardian(s): FORMTEXT      Address: FORMTEXT      Phone Number: FORMTEXT      2.Household Members (HHM):NAME:DOBSS#*RELATIONSHIP TO CHILDID CONFIRMED  MACROBUTTON [1] "Click Here and Type"  Describe the connections which make up the relationship with the child.  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 (see policy CFF 722-3) 3.Dates of contact with household members, including on-site visit:DATEWITH WHOMTYPE OF CONTACT  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      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.Has the child/children lived in the prospective guardian s home for at least 6 consecutive months? FORMTEXT      8.Prospective Guardian Relationship Status:Is the prospective guardian involved in a relationship? FORMTEXT      Describe the relationship?(Describe strengths of the relationship & areas need in 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 prospective guardian or any other household member? Describe. FORMTEXT      9.Substance Abuse:Does the prospective guardian or any household member have a substance abuse or alcohol problem? FORMTEXT      Is there a history of substance abuse or alcohol problems or treatment for any household member? FORMTEXT      10.Mental Health:Describe and evaluate the current mental and emotional health of the prospective guardian and household members. Is there a history of mental health problems or treatment for the prospective guardian or any household member? Has the prospective guardian or any household member participated in marriage counseling? Include current prescriptions for psychotropic medications. FORMTEXT      11.Physical Health:Describe the physical health of the prospective guardian. If physical health conditions are noted, describe how conditions would affect the care of the child(ren) in the home. FORMTEXT      12.Financial/Employment Status:List all sources of income for the household. 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, workmens compensation, etc., there must be an assessment of how that impacts the ability to care for the child. Describe the reasons why the guardian is not requesting guardianship assistance on behalf of the child. FORMTEXT      13.Day Care and Supervision:Discuss the prospective guardian s plans for day care if necessary. 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":"N""""#/#n#o#p#z#{#$ $ $$$$$D$F$~$$$$8%:%%%%%%%ڽڹڵڵڱڢڽڞڞڱړj?hv!Uh2jp=hv!UhDh nhhI hv!CJj;hv!U h#=hv! hv!5hv!jh!UmHnHujhv!Uj<9hv!U:!!!!!!| -$Ifgd{; $Ifgd{;_kd:$$If9Fh)+n(    4 9a $IfgdCin!!!!!!!ZOOO $Ifgd{;9kd<$$If9 ++4 9a $Ifgd{;_kd;$$If9Fh)+n(    4 9a!!!l#m#$$Ifa$gd{; $Ifgd{;_kdl<$$If9Fh)+n(    4 9am#n#o#$$ -$Ifgd{; $Ifgd{;_kd<$$If9Fh)+n(    4 9a$$$$$@$B$ZOOO $Ifgd{;9kdh>$$If9 ++4 9a $Ifgd{;_kd=$$If9Fh)+n(    4 9aB$D$F$%%%4_kd@?$$If9Fh)+n(    4 9a $Ifgd{;_kd>$$If9 Fh)+n(    4 9a%%%%%%%%|B9kd@$$If9 ++4 9a $Ifgd{;_kd8@$$If9Fh)+n(    4 9a -$Ifgd{; $Ifgd{;%%%%%%%&&Y'''''''( ( (((((V(X(p(((((((() ) ))))))))* "(*24fh jHhv!Uj6Fhv!UUjfDhv!UhHpjBhv!Uh h#=hv! hv!CJhv!jhv!Ujh!UmHnHu@%&&&&''_kdA$$If9Fh)+n(    4 9a $Ifgd{;'''(( -$Ifgd{; $Ifgd{;_kdA$$If9Fh)+n(    4 9a(((((R(T(ZOOO $Ifgd{;9kd C$$If9 ++4 9a $Ifgd{;_kdB$$If9Fh)+n(    4 9aT(V(X((((4_kdC$$If9Fh)+n(    4 9a $Ifgd{;_kdbC$$If9Fh)+n(    4 9a(()))))))M9kd^E$$If9 ++4 9a_kdD$$If9Fh)+n(    4 9a -$Ifgd{; $Ifgd{;))))$& -$Ifgd{;_kdE$$If9Fh)+n(    4 9a $Ifgd{;FORMTEXT      14.Sleeping Arrangements:Describe and view the sleeping arrangements for the child. FORMTEXT      15.Motivation for guardianship of the child(ren): Attitude of each member of the household toward accepting the child(ren). Attitudes towards the birth parent(s) and extended family. Describe the relationship between the child(ren)/youth and prospective guardian. Describe the prospective guardian s motivation to act as guardian for the child. FORMTEXT      16.The capacity for and willingness to fulfill the parental role for the child(ren) in their care: Discuss the prospective guardian s capacity and willingness to cooperate with the court, the school system, child s medical providers, child s therapist, the child s parent (if parental rights have not been terminated), etc. Discuss the prospective guardian s willingness to comply with the legal requirements of the guardianship, such as filing an annual report on the child s condition, complying with any court-ordered investigation, notifying the court of any change of address, etc. Address the prospective guardian s ability to protect the child(ren) from further harm. FORMTEXT      17.Prospective guardian s willingness to work with the child s birth family: Does the prospective guardian agree that they will not allow the child(ren) s parent(s) to live in their home without the court s approval? Do they agree to not release the child to anyone, including birth parents, without the court s approval? FORMTEXT      18.Prospective guardian s methods of behavior management and discipline of children: Discuss prospective guardian s method of behavior management.  FORMTEXT      19.Discuss the prospective guardian s abilities relative to the child(ren) s age and developmental needs. Describe their capacity and disposition to give the child guidance, love and affection. FORMTEXT      20.Is the prospective guardian committed to provide a stable living environment for the duration of childhood? Describe the prospective guardian s ability to provide permanence. FORMTEXT      21.Conclusion: Based on information gathered, summarize the prospective guardian s functioning as it applies to their capacity to care for the child(ren). FORMTEXT      22.Recommendation: Guardianship with prospective guardian is is not FORMCHECKBOX   FORMCHECKBOX recommended. FORMTEXT      Assigned Worker s Signature:Date:Supervisor s Signature:Date: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.cc:Case FileCourtParent(s)  (If parental rights have not been terminated.) 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