MDHHS-6175, MiFamily Together (Mift) Follow-up/Attempt Log

Michigan Department of Health and Human Services (MDHHS)

Children's Services Agency

(New 10-24)

Case Number

Section 1 – family information

Family Name	Family Phone Number

Family Street Address	City	State	Zip Code

MiFT Worker	Referring Worker	Referring Worker Phone Number

Referral Date	Closing Date	Follow-Up Month 3 Months 6 Months

Name of Child	Placement Code	Name of Child	Placement Code

Placement Codes:	07 Independent Living	16 Mental Health Facility	25 Out of State–Child Placement Agency
01 Own Home	09 Emergency Shelter Home/Facility	17 County. Treatment Facility	26 Out of State – Child Institute
02 Relative Home	10 Community Justice Center	19 Boarding School, etc. (Other)	27 Out of State – Licensed Relative
40 Unknown	11 Detention	20 AWOL	50 Re-Referral
03 Legal Guardian	12 Jail	22 Out of State – Parent	28 Deceased
04 Adoptive Home	13 Private Child Care Institution	23 Out of State – Unlicensed Relative
05 Family Foster Home (foster care)	14 DHHS Training School	24 Out of State Foster Home

Section 2 – follow up Attempts

Follow up attempt 1

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Contact Domestic Violence Staff Batterer returned? Substance Abuse Relapse? Contacted emergency contact Child Abuse Recurrence

Describe safety concerns/issues preventing face-to-face contact including possible or suspected return of batterer, child abuse recurrence, or substance abuse relapse.

follow up Attempt 2

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Contact Domestic Violence Staff Batterer returned? Substance Abuse Relapse? Contacted emergency contact Child Abuse Recurrence

Describe safety concerns/issues preventing face-to-face contact including possible or suspected return of batterer, child abuse recurrence, or substance abuse relapse.

follow up Attempt 3

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Contact Domestic Violence Staff Batterer returned? Substance Abuse Relapse? Contacted emergency contact Child Abuse Recurrence

Describe safety concerns/issues preventing face-to-face contact including possible or suspected return of batterer, child abuse recurrence, or substance abuse relapse.

follow up Attempt 4

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Contact Domestic Violence Staff Batterer returned? Substance Abuse Relapse? Contacted emergency contact Child Abuse Recurrence

Describe safety concerns/issues preventing face-to-face contact including possible or suspected return of batterer, child abuse recurrence, or substance abuse relapse.

follow up Attempt 5

Date	From	To

Type of contact or attempt and total time

Face to face	Phone	Travel	Collateral	Other

Contact Domestic Violence Staff Batterer returned? Substance Abuse Relapse? Contacted emergency contact Child Abuse Recurrence

Describe safety concerns/issues preventing face-to-face contact including possible or suspected return of batterer, child abuse recurrence, or substance abuse relapse.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.