DHS-665 (Rev. 4-12) MSWord 1
CHILDREN’S FOSTER CARE
PERMANENT WARD COURT REPORT
Michigan Department of Human Services
Begin Date:
End Date:
Court Date:
Foster Care Agency:
Foster Care Caseworker:
Court of Jurisdiction:
Jurist:
County of Commitment:
Court Docket #:
DHS Monitor:
Load #:
Adoption Agency:
Adoption Worker:
IDENTIFYING INFORMATION
Child(ren):
Name
Date of Birth
Case #
Date Entered Care
Date of Current Placement
Current Placement Type
Current Legal Status
Date of Parental Rights Termination
Permanency Goal
Anticipated Date for Achievement
Native American Inquiry Made
Native American Affiliation Confirmed (Tribe)
Date Caregiver Provided Notice of Hearing
I. PERMANENCY PLANNING
A. Agency Efforts To Achieve the Permanency Goal:
ADOPTION
Activity
Date
Activity
Date
Referral for Adoption Services
Subsidy Application Submitted
Adoptive Home Identified
Subsidy Contract Received
Child Assessment Completed
Consent Requested
Family Assessment Completed
Consent Received
Preliminary Family Assessment
completed, if applicable
Adoption Petition Filed with Court
MARE Registration
Finalization Hearing Set
Dates and Types of Recruitment Activities:
DHS-665 (Rev. 4-12) MSWord 2
Agency Efforts to Identify & Locate Relatives:
Barriers to Adoption Finalization:
Agency Efforts To Overcome Barriers To Adoption Finalization:
GUARDIANSHIP
Activity
Date
Activity
Date
DHS 2052 or DHS 2053 Completed
DHS 3310* Submitted
Court/MCI Approval of Permanency
Goal
DHS 2050 Completed
Home Study/Background Check
Completed
Guardianship Assistance Approved
Guardianship Petition Filed With Court
Guardianship Hearing Date
*Subsidized guardianship
Barriers to Guardianship Finalization:
Agency Efforts To Overcome Barriers To Guardianship Finalization:
PERMANENT PLACEMENT WITH FIT AND WILLING RELATIVE
Activity
Date
Activity
Date
Home Study/Background Check
Completed
Permanency Goal Approval DHS 344
Completed
Written Supervisory Approval
Permanency Goal Approval Received
from BCW Director
Court Approval of Permanency Goal
Permanency Goal Review, DHS 643
Completed, if required
Signed Relative Agreement, DHS-
845/846
Barriers To Placement With A Fit And Willing Relative Approval:
Agency Efforts To Overcome Barriers To Finalizing The Permanency Goal:
ANOTHER PLANNED PERMANENT LIVING ARRANGEMENT (APPLA)
Activity
Date
Activity
Date
PPC Held
DHS 343, DHS 843/844 Submitted to
Local DHS Director
DHS 643 Completed
DHS 343, DHS 843/844 Signed by
Local DHS Director
Court Hearing Order Received
Permanency Goal Approval Received
from BCW Director
Independent Living Goals and Services:
Barriers to APPLA Achievement:
DHS-665 (Rev. 4-12) MSWord 3
Agency Efforts To Overcome Barriers To APPLA Achievement:
ANOTHER PLANNED PERMANENT LIVING ARRANGEMENT – EMANCIPATION (APPLA-E)
Activity
Date
Activity
Date
PPC Held
DHS 341, DHS 642 Submitted to Local
DHS Director
Significant Connection to Responsible
Adult Identified
DHS 341, DHS 642 Signed by Local
DHS Director
DHS 643 Completed
Permanency Goal Approval Received
from BCW Director
Independent Living Goals and Services:
Barriers to APPLA-E Achievement:
Agency Efforts To Overcome Barriers To APPLA-E Achievement:
If youth is an MCI ward, has there been a redetermination of the appropriateness of placement with birth
parents?
If the case is to be closed prior to the next court hearing, address the following:
1. Reasons for case closure.
2. Specify the youth’s living arrangement and has the child’s needs are met.
3. Describe the youth’s means of employment or financial support.
4. Specify if the youth is or will be enrolled in a higher education or vocational program.
5. Specify referrals made to community resources and supports.
6. Indicate if the youth has adequate health insurance including transitional Medicaid.
II. PLACEMENT INFORMATION
A. Relative Search and Engagement Efforts
Agency ongoing relative search and engagement efforts.
Agency follow up activities with identified relatives.
Describe how identified relatives are involved in the case planning process.
B. Best Interest of Child’s Placement
C. ICWA Placement Preferences
DHS-665 (Rev. 4-12) MSWord 4
D. Sibling Placement and Visitation Plan
E. Placement Information
Child Name
Living Arrangement
Begin Date
End Date
If the child(ren) changed placement since last court hearing, summarize reason for placement change:
F. Foster Parent/Relative Caregiver Input:
III. CHILD WELL BEING
IV. RECOMMENDATIONS TO THE COURT/REQUEST FOR ORDER BY THE COURT
Attach a copy of the Updated Permanent Ward Services Agreement signed by all required parties.
Prepared and Approved by:
Court reports prepared by a private agency are submitted on behalf of the Department of Human Services.
DHS-665 (Rev. 4-12) MSWord 5
Signature:
Caseworker Name:
Date
Printed Name and Title
Phone #
Email
Fax #
Caseworker Signature
Supervisor Name:
Date
Printed Name and Title
Phone #
Email
Fax #
DHS-1280 (Rev. 3-12) MSWord 1
CHILDREN’S FOSTER CARE
INITIAL COURT REPORT
Michigan Department of Human Services
Begin Date:
End Date:
Court Date:
Foster Care Agency:
Foster Care Caseworker:
Court of Jurisdiction:
Jurist:
County of Referral:
Court Docket #:
DHS Monitor:
Load #:
IDENTIFYING INFORMATION
Child(ren):
Name
Date of Birth
Case #
Date Entered Care
Date of Current Placement
Current Placement Type
Anticipated Next Placement
Permanency Goal
Anticipated Date for Achievement
Concurrent Permanency Goal
Native American Inquiry Made
Native American Affiliation Confirmed (Tribe)
Date Caregiver Provided Notice of Hearing
Parents:
Name
Child
Legal Relationship
Removal Household
DOB
Present Address
Phone #
Agency Efforts To Locate Absent Parent(s):
Agency Efforts To Involve The Incarcerated Parent In Case Planning:
I. LEGAL INFORMATION
A. Reason for Removal:
B. Reasonable Efforts to Prevent Removal or Rectify Conditions That Caused Removal:
Services Offered
DHS-1280 (Rev. 3-12) MSWord 2
Reason Services Not Needed or Provided
C. Likely Harm To Child If Child Continues To Be Separated From Parents, Guardian Or Legal Custodian:
D. Likely Harm To Child If Returned To The Parent, Guardian Or Legal Custodian:
E. Mandatory Petition For Termination Of Parental Rights: YES NO
II. PLACEMENT INFORMATION
A. Agency Efforts To Locate Relatives For Placement:
B. Best Interest of Child(ren)’s Placement:
C. ICWA Placement Preferences:
D. Sibling Placement and Visitation Plan:
E. Placement Information:
Child Name:
Living Arrangement:
Begin Date:
End Date:
If the child(ren) changed placement, summarize reason for placement change:
F. Foster Parent/Relative Caregiver Input:
III. PERMANENCY PLANNING
A. Permanency Planning-Goal of Reunification
Specify the needs identified for each parent related to reasons for the child(ren) entering care.
Describe agency efforts to engage the parent(s), child(ren), and caregiver(s) in case planning and
development of the treatment plan.
List the specific needs the parent(s) and case manager identified as barriers to have the child(ren) returned
home. Specify the negotiated action steps as agreed upon in the Parent Agency Treatment Plan-Service
Agreement, and progress on each goal to date.
List specific service(s) and service provider(s) the parent(s) has been referred to, indicate level of participation,
or if services have been completed. Describe how the parent(s) has benefitted from services.
List barriers or unmet needs to reunification and what is being done to help remove barriers and address
unmet needs.
DHS-1280 (Rev. 3-12) MSWord 3
B. Parent-Child Visitation Plan
Describe the individualized plan to maintain or improve parent/child bond.
Specify frequency, location, and duration of visitation. Include whether visitation is supervised or
unsupervised.
Describe behaviorally specific objectives expected of the parent(s) during visitation.
Describe how the agency is assisting the parent(s) in meeting identified objectives.
Describe how the plan includes opportunities for parental participation in child’s life activities e.g., school
meetings, medical and mental health appointments, etc., if this is not part of the plan, provide explanation?
Describe parental compliance with visitation plan and quality of parent/child interactions during visitation.
Identify circumstances necessary to expand the frequency and duration of visitation.
C. Concurrent Planning
Describe all efforts to identify and implement concurrent permanency planning efforts consistent with the
identified concurrent permanency planning goal.
D. Relative Search and Engagement Efforts
Agency initial relative search and engagement efforts.
Agency follow up activities with identified relatives.
Describe how identified relatives are involved in the case planning process.
E. Agency Objectives/Action Steps Towards Achieving a Permanency Plan Other Than Reunification:
IV. CHILD WELL BEING
V. RECOMMENDATIONS TO THE COURT/REQUEST FOR ORDER BY THE COURT:
Attach a copy of the Initial Services Plan and Parent/Agency Service Plan/Treatment Agreement signed by all required
parties and attach reports from service providers.
Prepared and Approved by:
Court reports prepared by a private agency are submitted on behalf of the Department of Human Services.
Signature:
DHS-1280 (Rev. 3-12) MSWord 4
Caseworker Name:
Date
Printed Name and Title
Phone #
Email
Fax #
Signature:
Supervisor Name:
Date
Printed Name and Title
Phone #
Email
Fax #
DHS-1281 (Rev. 3-12) MSWord 1
CHILDREN’S FOSTER CARE
UPDATED COURT REPORT
Michigan Department of Human Services
Report Date:
Begin Date:
End Date:
Court Date:
Foster Care Agency:
Foster Care Caseworker:
Court of Jurisdiction:
Jurist:
County of Referral:
Court Docket #:
DHS Monitor:
Load #:
IDENTIFYING INFORMATION
Child(ren):
Name
Date of Birth
Case #
Date Entered Care
Date of Current Placement
Current Placement Type
Anticipated Next Placement
Permanency Goal
Anticipated Date for Achievement
Concurrent Permanency Goal
Native American Inquiry Made
Native American Affiliation Confirmed (Tribe)
Date Caregiver Provided Notice of Hearing
Parent(s):
Name
Child
Legal Relationship
Removal Household
DOB
Present Address
Phone #
Agency Efforts To Locate Absent Parent(s):
Agency Efforts To Involve The Incarcerated Parent In Case Planning:
I. LEGAL INFORMATION
A. Reason for Removal:
B. Likely Harm To Child If Child Continues To Be Separated From Parent, Guardian or Legal Custodian:
C. Likely Harm To Child If Returned To The Parent, Guardian Or Legal Custodian At This Time:
DHS-1281 (Rev. 3-12) MSWord 2
D. Reasonable Efforts The Agency Has Made To Achieve The Permanency Goal:
II. PLACEMENT INFORMATION
A. Agency Efforts to Locate Relatives for Placement:
B. Best Interest of Child(ren)’s Placement:
C. ICWA Placement Preferences:
D. Sibling Placement and Visitation Plan:
E. Placement Information:
Child Name
Living Arrangement
Begin Date
End Date
If the child(ren) changed placement since last court hearing, summarize reason for placement change:
E. Foster Parent/Relative Caregiver Input:
III. PERMANENCY PLANNING
A. Permanency Planning-Goal of Reunification
Describe agency efforts to engage the parent(s), child(ren), and caregiver(s) in case planning and
development of the treatment plan.
How has the parent(s) improved the conditions that brought the child(ren) into care? List the specific needs the
parent(s) and case manager identified as barriers to have the child(ren) returned home. Specify the negotiated
action steps as agreed upon in the Parent Agency Treatment Plan-Service Agreement, and progress on each
goal to date.
List specific service(s) and service provider(s) the parent(s) has been referred to, indicate level of participation,
or if services have been completed. Describe how the parent(s) has benefitted from services.
List barriers or unmet needs to reunification and specify activities to remove barriers and address unmet
needs.
B. Parent-Child Visitation Plan
Describe the individualized plan to maintain or improve parent/child bond:
Specify frequency, location and duration of visitation. Include whether visitation is supervised or
unsupervised.
Describe behaviorally specific objections expected of the parent(s) during visitation.
DHS-1281 (Rev. 3-12) MSWord 3
Describe how the agency is assisting the parent(s) in meeting identified objectives.
Describe how the plan includes opportunities for parental participation in child’s life activities e.g., school
meetings, medical and mental health appointments, etc. If this is not part of the plan, provide explanation?
Describe parental compliance with the visitation plan and quality of parent/child interactions during
visitation.
Describe circumstances necessary to expand the frequency and duration of visitation.
C. Concurrent Planning
Describe all efforts to identify and implement concurrent permanency planning efforts consistent with the
identified concurrent permanency planning goal.
D. Relative Search and Engagement Efforts
Agency ongoing relative search and engagement efforts.
Agency follow up activities with identified relatives.
Describe how identified relatives are involved in the case planning process.
E. Compelling Reasons For Not Filing Termination of Parental Rights (TPR) For Children Who Have Been In
Care For 15 Of The Last 22 Months:
F. Agency Objectives/Action Steps Towards Achieving A Permanency Goal Other Than Reunification:
IV. CHILD WELL BEING
V. RECOMMENDATIONS TO THE COURT/REQUEST FOR ORDER BY THE COURT
Attach a copy of the Updated Parent/Agency Service Plan/Treatment Agreement signed by all required parties and attach
reports from service providers.
Prepared and Approved by:
Court reports prepared by a private agency are submitted on behalf of the Department of Human Services.
DHS-1281 (Rev. 3-12) MSWord 4
Signature:
Caseworker Name:
Date
Printed Name and Title
Phone #
Email
Fax #
Signature:
Supervisor Name:
Date
Printed Name and Title
Phone #
Email
Fax #
