MDHHS

Foster Care Forms

Foster Care Forms

Caseworker Visit Tools
DHS-904 Foster Care/Adoption/Juvenile Justice Caseworker/Child Visit - Quick Reference Guide
Rev 01/20

DHS-904-A Foster Care/Adoption/Juvenile Justice Caseworker/Child Visit Tool
Rev 01/20
Court Reports
DHS-0665 CFC Permanent Ward Court Report
Rev 04/12

DHS-1280 CFC Initial Court Report
Rev 05/12

DHS-1281 CFC Updated Court Report
Rev 07/12

MDHHS-5964 Court Cover Letter
Rev 07/21
Credit & Identity Theft
Identity Theft Tip Sheet

DHS-762, Annual Credit Report Request
Determination of Care
DHS-470-A, Assessment for Determination of Care for Children in Foster Care Ages 13+
Rev 07/24

DHS-470 Assessment for Determination of Care for Children in Foster Care Ages 0-12
Rev 09/24

DHS-1254, SED Waiver Foster Home Payment Request and Approval
Rev 03/24

DHS-1945 Assessment for Determination of Care (DOC) for Medically Fragile Children in Foster Care
Rev 08/24
MiTEAM Practice Model & Family Team Meetings
DHS-1104, Family Team Meeting
Rev 05/15

Family Team Meeting Protocol
Rev 04/13

DHS-1104, Family Team Meeting Protocol - Spanish
Rev 05/15

DHS-1105, Family Team Meeting Report
Rev 11/24

DHS-1105-SP, Family Team Meeting Activity Report - Spanish
Rev 06/17

DHS-1107, A Caseworker's Guide to Pre-Meeting Discussions and Family Team Meetings
Rev. 03-16

DHS-1109, Family Team Meeting Invite
Rev 09/11

MDHHS-PUB-1160, A Family's Guide to Pre-Meeting Discussions and Family Team Meetings
Rev 11/15
Foster Care Additional Forms
Waiver of Foster Care Payments in Lieu of Government Benefits
Rev 04/22

DHS-30 Foster Parent/Caregiver Notice of Move
Rev 07/24

DHS-31 Foster Care Placement Decision Notice
Rev 07/21

DHS-57 Foster Care Transitional Medicaid
Rev 9/15

DHS-67A Treatment Foster Care Parent-Agency Treatment Plan and Service Agreement
Rev. 10/17

DHS-197 - Home Study Outline
Rev 05/15v

DHS-348, Michigan Works! Workforce Innovation and Opportunity Act Agency Referral
Rev 04/18

DHS-396 Residential Placement Exception Request
Rev 7/12

DHS-589 Recoupment Notice
Rev 06/14

DHS-594 Parental Placement of MCI Ward Request
Rev. 04-19

DHS-602 Adoption Referral
Rev 11/11

DHS-637 Caseworker Visit Report
Rev 8/08

DHS-649 Foster Care/Juvenile Justice Child Fatality Notification
Rev 06/15

MDHHS-710 Clearance to Publish Information on AWOLP Youth
Rev 09/23

DHS-715 Hearing Notice
Rev 06/21

DHS-715 Hearing Notice (Spanish)
Rev 06/21

DHS-715 Hearing Notice (Arabic)
Rev 06/21

DHS-719-CWFS, Child Welfare Funding Specialist Tool
Rev 07/24

DHS-786 Independent Living Plus Extension Request
Rev 1/14

DHS-790, Foster Parent Orientation Video Questions
Rev 07/11

DHS-867 - Notification to Court of Jurisdiction and Child's Lawyer Guardian Ad Litem
Rev 05/15

DHS-901-A, Semi-Annual Transition Plan Report, Youth Age 14-15
Rev 09/23

DHS-901-B, Semi-Annual Transition Plan Report, Youth Age 16 and Older
Rev 09/23

DHS-902, 90-Day Discharge Plan Report
Rev 02/19

DHS-942, School Notification and Education Records Release
Rev 10/24

DHS-945, Financial Aid Verification of Court/State Ward Status

DHS-956, Youth Housing Referral
Rev 10/18

DHS-1445, Child Support Confidential Locate Request
Rev 11/19

DHS-1476 Early Discharge of MCI Ward
Rev 05/17

DHS-1555-CS, Authorization to Release Confidential Information
Rev 05/17

DHS-2351-X, Bridges Provider Enrollment/Change Request
Rev 07/18

DHS-3198, Unauthorized Leave Notification
Rev 05/15

DHS 3198-A Unauthorized Leave Report to Court/Law Enforcement
Rev 10/23

DHS-3307 Placement Outline and Information Record
Rev 05/21

DHS-3377 Clothing Inventory Checklist
Rev 7/24

DHS-4527, Independent Living Agreement
Rev 9/17

DHS-5307 Rights And Responsibilities For Children and Youth In Foster Care
Rev 05/19

DHS-5307-SP Rights And Responsibilities For Children and Youth In Foster Care
Rev 5/19

DHS-5307-AR Rights And Responsibilities For Children and Youth In Foster Care
Rev 5/19

DHS-5331 Guidelines for Reasonable and Prudent Parent Standard
Rev 02/17

DHS-5333 Conversation Guide on Return from AWOLP
Rev 9/15

MDHHS-5406 - Bed Hold Payment Request
Rev 01/25

MDHHS-5406-CCI, Temporary Break Request
Rev 01/25

MDHHS-5406-IL, Bed Hold Payment Request for Independent Living Placements
Rev 01/21

MDHHS-5523, Human Trafficking Screening Tool - Ongoing Cases
Rev 06/17

MDHHS-5524, Human Trafficking Screening Tool - Closed Cases
Rev 06/17

MDHHS-5594, Trauma Assessment Referral
Rev 10/24

MDHHS-5599, Ancillary Service Approval
Rev 12/23

MDHHS-5748, Verification of Placement in Foster Care
Rev 07/18

MDHHS-5822, Pre-Approval Request for Foster Parent Mileage Reimbursement for Visitation Travel Over 150 Miles Round Trip
Rev 02/22

MDHHS-5829, Family Incentive Grant (FIG) and Unlicensed Relative Caregiver Funding
Rev 08/20

MDHHS-5841, Waiver of Foster Care Payments in Lieu of Government Benefits
Rev 11/23

MDHHS-5841-A, Waiver of Foster Care Payments in Lieu of Government Benefits
Rev 03/23

MDHHS-5853, GROW Training Referral
Rev 10/23

MDHHS-5855, Orthodontic Payment Agreement
Rev 07/22

MDHHS-5902 Caregiver Support and Resource Plan
Rev 10/23

Residential Referral Checklist - MDHHS-5928
Rev 04/22

MDHHS-5967, Overpayment Notification
Rev 07/21

MDHHS-6051, Child Welfare Placement Assistance Request
Rev 08/24

MDHHS-6070, Unlicensed Respite Provider Clearances
Rev 10/23

MDHHS-6071, Respite Services Exception
Rev 08/24

MDHHS-6072, Respite Child Information and Case Plan
Rev 02/25

MDHHS-6165, Provider Insurance Claim Request
New 03/25

For Forms Required for Interstate Compact, go to Interstate Compact Forms
Foster Care Supportive Visitation
DHS-599, Foster Care Supportive Visitation and In-Home Parent Education Referral
Rev 10/23

DHS-1469, Foster Care Supportive Visitation and In-Home Parent Education Visit Report
Rev 10/15

DHS-1470, Foster Care Supportive Visitation Termination Report
Rev 02/19

DHS-1471, Foster Care Supportive Visitation and In-Home Parent Education Initial Assessment
Rev 02/19

DHS-1472, Foster Care Supportive Visitation Service Agreement
Rev 010/20

DHS-1473, Foster Care Supportive Visitation and In-Home Parent Education Weekly Progress Report
Rev 02/18

DHS-1474 Foster Care Supportive Visitation and In-Home Parent Education Contract Compliance
Rev 10/20

MDHHS-5465, Family Satisfaction Survey Foster Care Supportive Visitation
Rev 10/16

MDHHS-5466, Referring Worker Satisfaction Survey, Foster Care Supportive Visitation
Rev 10/20

MDHHS-5716 - Foster Care Supportive Visitation and In-Home Parent Education Follow-Up Summary/Attempt
Rev 10/20
Permanency Goal Approval
DHS-347 - Permanency Goal Approval
Rev. 09/15

DHS-569 Permanency Goal Support Agreement
Rev. 08/15

DHS-643 - Permanency Goal Review
Rev. 08/15
Relative Search
DHS-541 Relative Licensing Referral Agreement
Rev 04/19

DHS-987, Relative Documentation
Rev. 05/15

DHS-987-SP Relative Documentation
Rev 05/15

DHS-990 Relative Notification Letter
Rev 03/21

DHS-990-SP, Relative Notification Letter (Spanish)
Rev 03/21

DHS-990-AR Relative Notification Letter (Arabic)
Rev 03/21

MDHHS-991 Diligent Search Checklist
Rev 05/16v

Relative Caregiving: What You Need to Know DHS-Pub-114
Rev 01/16

MDHHS-5770, Relative Placement Safety Screen
Rev 09/21
Residential Care
DHS-145 Family Assessment of Needs & Strengths
Rev. 10/15

DHS-365-A Children's Foster Care Residential Initial Service Plan (10-13 yrs)
Rev. 01/16

DHS-365 Children's Foster Care Residential ISP (4-9 yrs)
Rev. 12/15

DHS-365-B Children's Foster Care Residential Initial Service Plan (14 yrs and older)
Rev. 01/16

DHS-366-A Children's Foster Care Residential Updated Service Plan (10-13 yrs)
Rev. 12/15

DHS-366-B Children's Foster Care Residential Updated Service Plan (14 yrs and older)
Rev. 02/16

DHS-366 Children's Foster Care Residential Updated Service Plan (4-9 yrs)
Rev. 12/15

DHS-5335 Juvenile Justice Service Plan Addendum
Rev. 02/16

MDHHS-5931, Residential Aftercare Report
Rev. 08/24

MDHHS-5985, Incident Report
Rev. 12/21

MDHHS-5999, Residential Foster Care Abuse Neglect (RFCAN) and Residential Foster Care Juvenile Justice (RFCJJ) Contract - Qualified Residential Treatment Program (QRTP) Re-Certification
Rev. 03/25
Residential Care-Juvenile Justice
DHS-232 Initial Treatment Plan
Rev. 05/24

DHS-233 Updated Treatment Plan
Rev. 05/24

DHS-234 Release Report
Rev. 05/24

DHS-449 Juvenile Justice Reentry Care Coordination Referral
Rev. 01/20

MDHHS-Pub-1243-AR, Preventing Sexual Assault - Youth Orientation Packet (Arabic)
Rev. 04/19

MDHHS-Pub-1243, Preventing Sexual Assault - Youth Orientation Packet
Rev. 04/19

MDHHS-Pub-1243-SP, Preventing Sexual Assault - Youth Orientation Packet (Spanish)
Rev. 04/19

MDHHS-5520 Residential AWOLP and Escape Checklist
Rev. 03/18

MDHHS-5605, Juvenile Justice Residential Youth Orientation Checklist
Rev. 11/17

MDHHS-5606, Prison Rape Elimination Act (PREA) Screening Tool
Rev. 05/24

MDHHS-5606-AR, Prison Rape Elimination Act (PREA) Screening Tool (Arabic)
Rev. 05/24

MDHHS-5606-SP, Prison Rape Elimination Act (PREA) Screening Tool (Spanish)
Rev. 05/24

MDHHS-5799-PREA, PREA Retaliation Monitoring Log
Rev. 05/19

MDHHS-5809-PREA, Prison Rape Elimination Act (PREA) Investigation Tool
Rev. 08/19

MDHHS-5810-PREA, Prison Rape Elimination Act (PREA) Investigation Report
Rev. 03/21

MDHHS-5817-PREA, Annual Prison Rape Elimination Act (PREA) Staffing Plan Review
Rev. 08/19

MDHHS-5818-PREA, 30-Day Sexual Abuse Incident Review
Rev. 08/19

MDHHS-5830-PREA, Prison Rape Elimination Act (PREA) Unannounced Rounds Log
Rev. 11/19

MDHHS-5833-PREA, Prison Rape Elimination Act (PREA) Staffing Plan
Rev. 10/20

MDHHS-5931, Residential Aftercare Report
Rev. 08/24

MDHHS-5999, Residential Foster Care Abuse Neglect (RFCAN) and Residential Foster Care Juvenile Justice (RFCJJ) Contract - Qualified Residential Treatment Program (QRTP) Re-Certification
Rev. 05/22
Juvenile Justice Diversion and Reintegration Alternative Services
DHS-235, Juvenile Justice Community Based Support Plan

MDHHS-5680, Juvenile Justice Community Based Termination Report

MDHHS-5687, Juvenile Justice Diversion and Reintegration Alternative Services Referral Information

MDHHS-5689, Case Notes
SCAO Court Forms
Search for a Court Form
SDM Templates
DHS-69 Foster Care/Juvenile Justice Action Summary
Rev. 04/22
Supervisor Tools
DHS-1154 Foster Care Supervisory Guide
Rev 04/13

DHS-1155 Foster Care Supervisory Tool
Rev 07/13
Treatment Foster Care
DHS-65A Treatment Foster Care Initial Service Plan
Rev. 10/17

DHS-66A Treatment Foster Care Updated Service Plan
Rev. 10/17

DHS-67A Treatment Foster Care Parent-Agency Treatment Plan and Service Agreement
Rev. 10/17

DHS-68A Treatment Foster Care Permanent Ward Service Plan
Rev. 10/17

DHS-974 Treatment Foster Care Extension Request
Rev. 09/09

DHS-975 Treatment Foster Care Exception Request
Rev. 10/09

DHS-976 Treatment Foster Care Denial of Referral
Rev. 04/14

DHS-977 Treatment Foster Care Referral Acceptance
Rev. 12/08

DHS-978 Treatment Foster Care Placement Request
Rev. 05/18

DHS-979 Treatment Foster Care Discharge Report
Rev. 03/09
Well Child Exams & Other Health Forms
DHS-193, Foster Care Transitional Medicaid (FCTMA)
Rev. 01/15

DHS-Pub-268, Guidelines for Foster Parents and Relative Caregivers for Health Care and Behavioral/Mental Health Service
Rev. 06/23

DHS-Pub-268-AR, Guidelines for Foster Parents and Relative Caregivers for Health Care and Behavioral/Mental Health Service (Arabic)
Rev. 06/23

DHS-Pub-268-SP, Guidelines for Foster Parents and Relative Caregivers for Health Care and Behavioral/Mental Health Service (Spanish)
Rev. 06/23

DHS-0439, Notice of Health Care Coverage for Former Foster Youth Extended to Age 26
Rev. 11/15

DHS-579, Well Child Exam Infancy: 4 Weeks
Rev. 04/16

DHS-580, Well Child Exam Infancy: 1 Week Visit
Rev. 06/15

DHS-581, Well Child Exam Infancy: 4 Months
Rev. 06/15

DHS-0583, Well Child Exam Infancy: 2 Months
Rev. 08/11

DHS-1147 - Foster Care Youth Health Services Refusal
Rev. 05/19

DHS-1556, Behavioral/Mental Health Exception
Rev. 08/17

DHS-1631, Well Child Exam Early Childhood: 18 Months
Rev. 06/15

DHS-1632 Well Child Exam Early Childhood 2 Years
Rev. 06/15

DHS-1633, Well Child Exam Early Childhood: 30 Months
Rev. 07/15

DHS-1634 Well Child Exam Early Childhood 3 Years
Rev. 04/16

DHS-1635 Well Child Exam Early Childhood 5 Years
Rev. 06/15

DHS-0381 Well Child Exam Middle Childhood 6-10 Years
Rev. 06/15

DHS-1636, Well Child Exam Early Adolescence: 11-14 Years
Rev. 07/11

DHS-1637 Well Child Exam Early Adolescence: 15 - 18 Years
Rev. 08/15

DHS-1638, Well Child Exam Early Childhood: 9 Months
Rev. 07/11

DHS-1639, Well Child Exam Early Childhood: 12 Months
Rev. 08/11

DHS-1640, Well Child Exam Early Childhood: 15 Months
Rev. 06/15

DHS-1641, Well Child Exam Infancy: 6 Months
Rev. 06/15

DHS-1642, Well Child Exam Early Childhood: 4 Years
Rev. 08/11

DHS-1643, Psychotropic Medication Informed Consent
Rev. 03/21

DHS-1664, Youth Dental Exam
Rev 10/21

MDHHS-5338, Foster Care Well Child Exam/EPSDT Appointment Verification
Rev. 12-15
Young Adult Voluntary Foster Care
DHS-38, Verification of Employment
Rev. 12/07

DHS-54A, Medical Needs
Rev. 10/08

DHS-333, YAVFC Poster
Rev. 7/13

DHS-650-YA, Young Adult Extension Unit Checklist
Rev. 09/19

DHS-1295, Young Adult Monthly Visit Report
Rev. 12/18

DHS-1297, Young Adult Voluntary Foster Care Agreement
Rev. 10/22

DHS-1297-SP, Young Adult Voluntary Foster Care Agreement (Spanish)
Rev. 10/22

DHS-1301-YA, Young Adult Voluntary Foster Care Case Denial/Closure Notice
Rev. 02/25

DHS-1302, Young Adult Voluntary Foster Care Case Closure Request
Rev. 05/17

DHS-3380, Verification of Student Information
Rev. 10/12

MDHHS-5778, Young Adult Voluntary Foster Care Verification of Eligibility
Rev. 02/20