ABUSE/NEGLECT RESIDENTIAL UPDATED SERVICE PLAN
Michigan Department of Human Services
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
Teaching-Family Homes of Upper MichiganDHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
Date of Report: / Report Period: / throughI. Identifying Information
A. Child: / Enter the child’s name, date of birth, case number, the facility name, specific program name and address of the facility, date entered out of home placement, current placement type, date of current placement, and the next anticipated placement of the child and the anticipated placement date as specified by DHS. Indicate the permanency planning goal (as specified by DHS), sex, and race of the child.
Name: / Date of Birth: / Case Number:
Child’s Address if not FH: / Date Entered Care:
Current Placement Type: / Date of Current Placement: / Anticipated Next Placement Type: / Date Anticipated Next Placement:
Foster HomeInd. LivingRelativeResidentialAdoptive HomeOwn HomeOther / Foster HomeRelativeResidentialAdoptive HomeOwn HomeInd. LivingOther
Perm. Plan Goal / Sex: / Race: / Check if Ethnicity
is Hispanic/Latino:
6 = Emancip. By Age 197 = Plcmt. Relatives8 = Reunification10 = Adoption12 = Perm. FFA13 = Maint. Own Home / MF / WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian/Other Pacific IslanderUnable to Determine
B. Parent (Caretaker) Name(s): For each adult parent or caretaker, non-parent adult with a significant relationship or who is a potential placement, provide the name and relationship to child, the address and telephone number, date of birth, sex and race of the person.
Name: / Relationship: / Date of Birth:
Parent’s Current Address: / Telephone:
Sex: / Race: / Check if Ethnicity is Hispanic / Latino:
MF / WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian/Other Pacific IslanderUnable to Determine
C. Commitment or Referral Information:
DHS Local Office Name: / DHS Worker Name: / DHS CDUL No’s.: / DHS Worker Telephone:
POS Agency Name: / POS Agency Worker Name: / POS Agency Telephone:
Court ID Number: / Judge’s Name: / Judge’s Telephone:
II. / Legal Status
Add the information in this section as requested. Initial Wardship is TCW or MCI Ward as specified by the DHS worker. In the space following this section, add any pertinent narrative concerning court requirements.
Initial Wardship Type and Date / Last Court Type and Date
Current Wardship Type and Date / Next Court Type and Date
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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III. / Social Work ContactsList date, person contacted, role/position, type of contact (telephone, in person, home visit, office visit, etc.) for each contact, attempted contact, and scheduled, but unkept, appointment. If desired, provide a brief narrative statement of the specific reason for the contact. Limit the narrative to one sentence.DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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IV. / Child AssessmentA. / Child Status
. / Describe for the child addressed in this report; emotional and physical development, past experiences and, problems since the most recent assessment. Include a physical description of the child, hobbies, likes and dislikes, etc and any changes since the most recent assessment and report. Describe the child’s adjustment to residential placement and services.
Describe the services provided, offered to or planned for the child, parent(s), guardian, or custodian, and non-parent adult including potential placements, if applicable, to return the child home or move to less restrictive placement. Discuss planning for aftercare.
Indicate the anticipated next placement and the projected time frame for the placement.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Address and explain each individual item scored as strength or need on the Child Assessment of Needs and Strengths for the child in the space provided following each item. Provide the reasons that each item is scored as a strength or need. If there are significantdiscrepancies between facility scoring of any need item and the worker with primary family responsibility, it must be identified and resolved through a conference with the family worker.B. / Child Needs and Strengths Assessment
Item / C1. / Emotional Behavior/Coping Skills If the child has limited or severely limited emotional behavior, a DSM or other clinical diagnosis must be included as support for the scoring of the item.
a. Exceptional Emotional Behavior/Coping skills...... +3
b.Appropriate Emotional Behavior/Coping skills...... 0
c.Limited Emotional Behavior/Coping skills...... -3
d.Severely Limited Emotional Behavior/Coping skills...... -5 / +30-3-5
Item C1EMOTIONAL BEHAVIOR/COPING SKILLS
A.Exceptional Emotional Behavior/Coping Skills - Child utilizes strong coping skills and deals effectively with crises, trauma, disappointment and daily challenges. Child has a positive and hopeful attitude, and has the ability to adjust to new situations.
B.Adequate Emotional Behavior/Coping Skills - Child displays developmentally appropriate emotional/coping responses that do not or only minimally interfere with school, family or community functioning. May demonstrate some symptoms reflecting situational sadness, anxiety, aggression or withdrawal.
C.Limited Emotional Behavior/Coping Skills - Child has some difficulty dealing with daily stresses, crises, or problems which interfere with school, family and/or community functioning. Problems may include, but not limited to, withdrawal from social contact, flat affect, changes in sleeping or eating patterns, increased aggression, low frustration tolerance, etc.
D.Severely Limited Emotional Behavior/Coping Skills - Child has chronic difficulty dealing with daily stresses, crises, or problems which severely impair school, family and/or community functioning. Child may have diagnosed psychiatric disorder and may demonstrate behaviors such as fire setting, suicidal behavior, violence toward people and/or animals, self-mutilation, etc. Child is a chronic runaway from placement.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Item / C2. / Medical/PhysicalDescribe any physical/medical/dental/optical issues (past and present) for the child since the most recent assessment including
- Current medication and dosage,
- Physicals, dental exams or eye exams since the most recent assessment,
- Known medical issues and medications for the child and
- A listing of appointments and outcomes for the child for medical and dental concerns.
Was there prenatal drug/alcohol exposure? / YesNoUnknown
a.No Health Care Conditions...... +2
b.Health Care Conditions that do not impair functioning...... 0
c.Health Care Conditions that impair functioning...... -2
d.Health Care Conditions that severely impair functioning...... -4 / +20-2-4
Item C2MEDICAL/PHYSICAL
Prenatal drug exposure? __yes ___no ___unknown
A.No Health Care Conditions. Child has no known health care conditions.
B.Health Care Conditions That Do Not Impair Functioning. Child has some health care conditions but they do not impair daily functioning
C.Health Care Conditions That Impair Functioning. Child has health care conditions that impair daily functioning and/or special conditions exist that require ongoing interventions.
D.Health Care Conditions That Severely Impair Functioning. Child has serious, chronic, or acute health care conditions that severely impair functioning or requires ongoing intervention.
*Health care conditions are all physical conditions a child may have including medical, dental, vision and hearing.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Item / C3. / Substance Usea.No substance use...... +2
b.Past experimentation or too young to score...... 0
c.Current substance use ...... -2
d.Chronic substance use...... -4 / +20-2-4
Item C3SUBSTANCE USE
A.No Substance Use. - Child does not use alcohol, drugs or other substances and is aware of consequences of use. Child avoids peer relations/social activities involving alcohol, drugs and other substances and/or chooses not to use despite peer pressure/opportunities to use.
B.Past Experimentation or Too Young To Score. - Child is too young to score this category or child may have experimented with alcohol, drugs or othersubstances, but there is no indication of sustained use. No demonstrated history or current problems related to substance use.
C.Current Substance Use. - Child's alcohol, drugs or other substance use has resulted in disruptive behavior and discord in relationships in school/community/family/work. Use has broadened to include multiple drugs.
D.Chronic Substance Use. - Child's chronic alcohol, drug or other substance use results in severe disruption of functioning such as loss of relationships, job, school suspension/expulsion/dropout, problems with the law, and/or physical harm to self or others. Child may require medical intervention to detoxify.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Item / C4. / Family and Kin/Fictive Kin RelationshipsDescribe any relationships of the child (including parents, siblings, relatives, non-parent adults, foster parents, potential relative or fictive kin placements and any other past or projected placement) for the child that are important for;
the reduction of the child’s needs,
subsequent placement to a less restrictive setting. ; and
how ongoing relationships will be supported
If the youth is an MCI (permanent ward) and does not have an identified family, indicate that in the narrative for this item) and provide any relevant information about the family.
a.Nurturing/Supportive Relationships/Attachments...... +2
b.Adequate Relationships/Attachments...... 0
c.Limited Relationships/Attachments...... -2
d.Severely Limited Relationships/Attachments...... -4 / +20-2-4
Item C4FAMILY AND KIN/FICTIVE KIN RELATIONSHIPS/ATTACHMENTS
A.Nurturing/Supportive Relationships/Attachments. Child experiences positive interactions with family and fictive kin members. Child has sense of belonging. Roles are defined, clear boundaries exist and child's growth and development is supported.
B.Adequate Relationships/Attachments - Child experiences positive interactions with and exhibits appropriate attachments to family and fictive kin members despite some stress and discord.
C.Limited Relationships/Attachments Stress/discord within family and fictive kin network limits positive interactions. Child has difficulty forming and maintaining appropriate attachments to family and fictive kin members.
D.Severely Limited Relationships/Attachments. Chronic stress, conflict or violence severely limits positive interactions. Child has extreme difficulty developing and/or fails to form and maintain appropriate attachments to family and fictive kin members.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Item / C5. / Sexual Adjustment/Victimization If the child is a victim of sexual abuse, indicate this in the narrative section following regardless of the child’s current functioning.a.Healthy adjustment/responsible behavior...... +2
b.Appropriate adjustment/behavior...... 0
c.Compromised adjustment/behavior ...... -2
d.Severely impaired adjustment/Reckless behavior...... -4 / +20-2-4
Item C5SEXUAL ADJUSTMENT/VICTIMIZATION
A.Healthy adjustment/responsible behavior – No behavioral signs or history of sexual abuse or exploitation. Child has accurate knowledge of sexuality and reproduction. Child demonstrates responsible choices.
B.Appropriate adjustment/behavior – No behavioral signs of sexual abuse or exploitation or the child may be asymptomatic of past abuse and responding to treatment/intervention. Child may participate in age-appropriate sexual behavior or may show age-appropriate interest in sexual materials/topics.
C.Compromised adjustment/behavior – Known or suspected sexual abuse or exploitation and the child is displaying impaired functioning. Behaviors may include more sexualized behaviors than same aged children; preoccupation with sexual themes, increased masturbation and/or simulating sex acts with dolls/toys. Older children may exhibit irresponsible sexual behavior. For example, unprotected sex or multiple partners.
D.Severely impaired adjustment/Reckless behavior – Child exhibits severe sexual dysfunction. Indicators may include perpetrating behaviors (involving force or coercion), severe sexual preoccupation, compulsive masturbation (may include objects) and sexual victimization. Older children may become involved in illegal sexual activity such as prostitution or pornography.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Item / C6. / Education / Early Intervention -Discuss the child’s current educational status, if applicable, including:- The type and location of the school
- grade and type (Reg. Ed., EI, LD, etc.) and
- progress in school since placement
Does Child Need Special Education/Early Intervention? / YesNoUnknown
Does Child have a Special Ed./Early Intervention in Place? / YesNo
a.Exceptional academic achievement +1
b.Adequate achievement 0
c.Minor difficulty -1
d.Major/chronic difficulty -3 / +10-1-3
Item C6EDUCATION/EARLY INTERVENTION
Does child need a Special Education/Early Intervention plan? Yes__ No__ Unknown ___
Does child have a Special Education/Early Intervention plan in place? Yes__ No__
A.Exceptional Academic Achievement. Child is working above grade level and/or is exceeding the expectations of the child's specific educational/early intervention plan.
B.Adequate Achievement. Child is working at grade level and/or is meeting expectations of the child's specific educational/early intervention plan. Child not yet school age and no special interventions needed.
C.Minor Difficulty. Child is working below grade level in at least one, but not more than half of subject areas and/or child is struggling to meet the goals of the existing educational/early intervention plan. Existing educational plan may need modification. Minor truancy or school behavioral problems. Child has legally dropped out of school and has no current educational plan. Child not yet school age has minor developmental and/or cognitive delays.
D.Major/Chronic Difficulty. Child is working below grade level in more than half of subject areas and/or child is not meeting the goals of the existing educational/early intervention plan. Existing educational plan needs modification or child does not have a plan which is needed. Score this item for a child who is legally required to attend school and is not attending, or who has been expelled/excluded from school. Child not yet school age has major developmental and/or cognitive delays.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Item / C7. / Child Development/Life Skillsa.Advanced development ...... +1
b.Age-appropriate development ...... 0
c.Limited development ...... -1
d.Severely limited development ...... -3 / +10-1-3
Item C7CHILD DEVELOPMENT/LIFE SKILLS
For this item base assessment on developmental milestones as described in the instructions of stages of development.
A.Advanced Development. - Child's physical and/or cognitive development is above chronological age expectations. Consistently demonstrates appropriate life skills.
B.Age-Appropriate Development. - Child's physical and/or cognitive development is consistent with chronological age level. No evidence of life skills deficits.
C.Limited Development. - Child's physical and/or cognitive development is delayed. Does not consistently demonstrate age appropriate life skills; needs some intervention to manage daily routine.
D.Severely Limited Development. - Child's physical and/or cognitive development is severely delayed. Does not demonstrate age appropriate life skills, requires extensive training and assistance to manage daily routine.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Item / C8. / Cultural/Community Identitya.Strong cultural/community identity...... +1
b.Adequate cultural/community identity...... 0
c.Limited cultural/community identity...... -1
d.Disconnected from cultural/community identity...... -3 / +10-1-3
Item C8CULTURAL/COMMUNITY IDENTITY
A.Strong Cultural/Community Identity. Child identifies with cultural and community heritage and beliefs and is connected with people who share similar belief systems. Child knows cultural/community resources, both formal and informal, and accesses them as needed.
B.Adequate Cultural/Community Identity. Child is exposed to or identifies with cultural/community heritage and beliefs, practices, and traditions within the family. Child recognizes how to access resources in the greater community. Child may experience some conflict and may struggle with cultural/community identity, yet is able to cope.
C.Limited Cultural/Community Identity. Child experiences inter-generational and/or societal conflict surrounding values and norms related to cultural/community differences. Child perceives services and supports as unavailable or access as limited. Conflicts with cultural/community identity create difficulties for child.
D.Disconnected From Cultural/Community Identity. Child is disconnected from cultural/community heritage and beliefs resulting in isolation, lack of support, and lack of access to resources. Connections are unavailable, or child perceives as unavailable, due to lack of understanding of cultural and language differences of support networks. Conflicts with cultural/community identity result in problematic behaviors as exhibited by child.
DHS-366 (Rev. 10-05) MSWord1Residential USP (10-05) Mental Health Version
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Item / C9. / Peer/Adult Social Relationships (Non Family)a.Strong Social Relationships...... +1
b.Adequate Social Relationships...... 0
c.Limited Social Relationships...... -1
d.Poor Social Relationships...... -2 / +1 0-1-2
Item C9PEER/ADULT SOCIAL RELATIONSHIPS (non family)
A.Strong Social Relationships. Child enjoys and participates in a variety of constructive, age appropriate activities. Child enjoys reciprocal, supportive and positive relationships with others.
B.Adequate Social Relationships. Child demonstrates adequate age appropriate social skills. Child maintains stable relationships with others and demonstrates ability to resolve conflicts.