ࡱ>  @ Szbjbj E8"""""""6@@@8h|6xT46ACDDDDEtF<QSSSSSS$URWS]"7GDD7G7GS""DD2THHH7G"D"DQH7GQHH""HD x= @MG"HUIlHT0xTHXoG6XH66""""X"HSF"uFHFFSFSFSFSS66":)H66:)CAREGIVER S PERMANENCY PLANNING CHECKLISTDepartment of Human ServicesState of MichiganChild s Name: FORMTEXT      Child Placing Agency: FORMTEXT      Child s Case Number: FORMTEXT       FORMTEXT      Caseworker s Name: FORMTEXT      Caregiver(s) Name and Address: FORMTEXT       FORMTEXT       FORMTEXT      Date Completed: FORMTEXT      Section 1CAREGIVER(S) QUESTIONSPlease respond to following statements for the child(ren) in your care. A single form can be used for siblings unless a child in the sibling group has needs that should be considered individually.Check OneYesNoa. I believe the best plan is for the child(ren) to stay with me as part of my family. FORMCHECKBOX  FORMCHECKBOX b. I am capable and interested in caring for the child(ren) without the support of a caseworker. FORMCHECKBOX  FORMCHECKBOX c. I have the support from family, friends, community, etc., needed to raise the child(ren). FORMCHECKBOX  FORMCHECKBOX d. I am willing and able to address the child(ren)s educational, health, mental health, and other needs. FORMCHECKBOX  FORMCHECKBOX e. I am willing and able to manage visits/relationships between the birth parent(s) and child(ren) to ensure the child(ren)s safety. (If applicable) FORMCHECKBOX  FORMCHECKBOX f. I am willing and able to continue providing a safe and stable home environment for the child(ren). FORMCHECKBOX  FORMCHECKBOX g. I do not have any health conditions that limit my ability to care for the child(ren). FORMCHECKBOX  FORMCHECKBOX h. I agree that the child(ren) is a permanent member of my family. FORMCHECKBOX  FORMCHECKBOX i. I am requesting guardianship assistance to help in the cost of supporting the child(ren) and am willing to be licensed as a foster parent. FORMCHECKBOX  FORMCHECKBOX j. I am willing to maintain any public or private medical insurance or assistance for which the child is eligible. FORMCHECKBOX  FORMCHECKBOX k. I am willing to cooperate with DHS and the court to provide all information required and will comply with filing an annual report of the child(ren)s status in my home. FORMCHECKBOX  FORMCHECKBOX Section 2ADOPTION RULE OUT CRITERIA(Check all that apply)Specific life issues prevent the caregiver from pursuing adoption: FORMCHECKBOX Marital/Divorce issues FORMCHECKBOX Cultural issues FORMCHECKBOX Desire to maintain current relative status (i.e., grandparent, aunt, uncle, etc.) FORMCHECKBOX Other FORMTEXT       FORMCHECKBOX Youth does not want to be adopted (age 14 and over*). Please list all information, counseling and peer mentoring the youth has received in making this decision: FORMTEXT      Section 3SELECTING A PERMANENCY GOALPlace a check in the box above the permanency goal that is most appropriate for the child(ren) in your care. If all of the answers in section 1 are yes, adoption should be pursued for the child unless one of the adoption rule out criteria in section 2 is checked. If there any no answers in section 1, the Alternative Goal box should be checked and another permanency goal identified. 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V<kd $$Ifl4y,y,4 lalf4 $Ifgd(,bkdL $$Ifl4F')y,'    4 lalf489:QZNB $$Ifa$gdR $$Ifa$gdROkd!$$Ifl408y,8A(4 lalf4 $$Ifa$gd) $$Ifa$gd)<kdJ!$$Ifl4y,y,4 lalf4QRSTf] $Ifgd)<kd"$$Ifl4y,y,4 lalf4 $$Ifa$gd)Okd"$$Ifl408y,8A(4 lalf4|j^ $$Ifa$gd)d8$If^gd)<kd:#$$Ifl4y,y,4 lalf4 $Ifgd)<kd"$$Ifl4y,y,4 lalf4AOkd$$$Ifl40hy,h+4 lalf4 $$Ifa$gd)d8$If^gd)Okd$$$Ifl40hy,h+4 lalf4 $Ifgd) $$Ifa$gd)d8$If^gd)Okd%$$Ifl40hy,h+4 lalf4bdxz|rt  !"#12345>J濷暖umihddhp9OJQJj,hCgNUj`,hCgNUj+hCgNUhp9jhp9Uhha!\h)5>* h)5>*ha!\h)5 h)5j)hUhjhUj8(hCgNUh)jh)UjhCgNUmHnHu)C1d8$If^gd)<kd'$$Ifl4y,y,4 lalf4 $Ifgd)ukd2'$$Ifl4\h8y,h [4 lalf4^`bAOkd)$$Ifl40hy,h+4 lalf4 $Ifgd) $Ifgd)Okd($$Ifl40hy,h+4 lalf4 $$Ifa$gd)fZN $$Ifa$gd) $$Ifa$gd)OkdT*$$Ifl408y,8A(4 lalf4 $$Ifa$gddd<kd)$$Ifl4y,y,4 lalf4f] $Ifgd)<kd<+$$Ifl4y,y,4 lalf4 $$Ifa$gd)Okd*$$Ifl408y,8A(4 lalf4"45>KfVJJJ $$Ifa$gdbkdH-$$Ifl4F8 y,8"    4 lalf4 $Ifgd<kd+$$Ifl4y,y,4 lalf4Jfgqrr r rrrrr@rFrHrTrVrjrlrnrxrzr|r~rrrrrrrrrrrrr;՘}yumubmmu\ h zCJjx1h zUjh zUh zh)hp9CJOJQJ hp9CJjr/h+wUjhp9Uhhp9@OJQJaJhh@OJQJaJhh z@OJQJaJhp9OJQJjhCgNUmHnHuUj-hCgNUhCgNjhCgNUhp9$     Caregiver s Signature(s)Date FORMTEXT      Date FORMTEXT      Caseworker s SignatureDate FORMTEXT      Caseworker Supervisor s SignatureDate FORMTEXT      Section 4YOUTH S STATEMENT(*Required for a child 14 years or older, optional for children under 14)I have discussed my permanency options with the caseworker and my caregiver and I agree that the selected permanencygoal above is the best plan for me.Child s SignatureDate FORMTEXT      Child s SignatureDate FORMTEXT      Child s SignatureDate 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. DHS-2051 (Rev. 7-09) Previous edition obsolete. 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J< 9stdole>stdoleP f%\*\G{00020430-C 0046}#2.0#0#C:\WINNT\System32\StdOle2.tlb#OLE Automation/MSForms>SFErms/z pF7C79B5C0-E6E6-11D2-9439FC01`A86E5F3.TWD#Micr@osoft = ` Ob Library9Ph0jP5926339E-587D-441B-9117-6D845226APTEMP\VHBE\&EX&.E .`M ACvOfficDvOA@sficBv)*2DF8D04C-5BFA-10*BDE5SAA@u42*gram Files\O\MSO97.DLLHX 8.0X"5BThisDocumentN2@1Th@6sDcu(en@ HB1B,B5"B+BMyIPnfo2MyIf@OD'Ou!HK)^rU~~~~~~~~l A{k-I>H3     )x5u"'(6 << <AB?$*\Rffff*ed4212466d `@`Enter Personal Information1Normal.MyInfo.MainG2@ h'P\(4P^@P(MP`jPbPdhPf(PhPjȬPlPnhPp`Pr PtPv0PxPzP|P~`, Z⤗$HpME " (08@HPX`hpx &((0*X&(&&((&P$x&$$&$@&h&(N$0$X&&*$"(0PT$$(H hx <468H6864(6`846 4@ 2x 2 4 2 4X : : 2 H ` & 4 6 8 6P 8 6 4 60 8h 4 6 42H2424(:`: "0284p2420P2402 0X..0.0H6x6 ":>PB>F2`:>66P.2::02p62BF` 4 2 & (@ *h .  2 4 X ` p ZxZZZZZZZ Z8ZPZhZZZZZZZZ(Z@DEFINE DIALOG BOXF,MyInfo B@$m ^YourName B@&m8^ YourTitle B@&mP^ YourOffice B@&mi^ YourAddress B@&nxYourCity B@&T( YourState B@&FYourZip B@&n(AreaCode B@&P YourPhone B@&<YourExt B@&r(FAXAC B@&PYourFax B@&(YourCO B@&(YourDI B@&(YourSEC B@&T(YourUN B@&(YourWKR B@&m^BossName B@&m^ BossTitle B@&k  /Enter the following information about yourself. 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