State of Michigan
Department of Human Services
Bureau of Juvenile Justice
Period Covered to
CASE NAME / DATE OF BIRTH / DHS CASE #
COUNTY / ADMISSION DATE / RECIPIENT ID #
JJS / SERVICE PROVIDER/AGENCY / COURT CASE #
JJS LOAD # / COURT
PHONE #: / TEAM LEADER
USP RECEIVED: Yes / No
CURRENT / HIGHEST ADJUDICATED OFFENSE
SECURITY LEVEL
REFERRAL/COMMITMENT DATE
PHONE #:
VICTIM NOTIFICATION REQUEST / CURRENT / MONTHS IN TREATMENT
RISK LEVEL
Yes / No / PERIOD COVERED
PARENT or GUARDIAN’S NAME(S)
PHONE #:
I. / COURT UPDATE (Note any pending hearings; summarize outcomes of hearings since last updated service plan; document notices to court and specify date sent. Include status of plan to implement court ordered payments and community service).
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II. / SUMMARY FOR COURTDescribe:
1. / The services and programs currently being utilized by, or offered to, the juvenile and the juvenile’s participation in those services or programs (including education, counseling and work programs), which are not included in section IV below.
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2. / The juveniles willingness to accept responsibility for prior behavior.DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word 1
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3. / The juvenile’s behavior in the current placement.DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word 1
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4. / The juvenile’s efforts toward rehabilitation.DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word 1
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5. / The physical and mental maturity of the juvenile as they relate to the prior record and character of the juvenile.DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word 1
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6. / The juveniles potential for violent conduct as demonstrated by prior behavior.DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word 1
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7. / Eligible for release based on the FIA risk reassessment instrument? Make a recommendation for the youth’s release or continued custody.DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word 1
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III. / CASE MANAGEMENTA. / Contacts
Date / Person Contacted / Type of Contact / Purpose
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B. / Participants:Youth: / Gave Input / Did Not Give Input
Parent/Guardian: / Gave Input / Did Not Give Input
JJS: / Gave Input / Did Not Give Input
YGL/SW: / Gave Input / Did Not Give Input
Other: / Gave Input / Did Not Give Input
C. / If listed participant did not give input, document the reason.
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IV. / PROGRESS MADE TOWARDS MEETING NEEDS/STRENGTHS AND TREATMENT GOALS ESTABLISHED IN THE PREVIOUS TREATMENT PLAN. Address each strength/need listed below. No more than four goals based on priority should be listed, excluding educational and family goals. The goals may encompass more than one area of identified need. Family reunification goals must be balanced against the need for community safety. For each goal, state the long term goal, short term measurable objective, indicators of goal achievement, the time frame for achieving the goal, the progress made/or completion of each goal from prior treatment plans, individuals responsible for coordinating and implementing strategies to achieve the goals, and staff techniques for addressing the youth’s goals. Include the youth’s statement and attitude about the offense and impact on the victim and community.DEFINITIONS:
GOALS:
Goals should be broad based general statements of what the youth and family need to address identified problem areas or support strength areas.
OBJECTIVES:
Most goals will need incremental objectives or outcomes desired to meet the broad based goals. These could be considered the small successes that a youth or family could experience on the way toward meeting the over all goal.
INDICATORS:
A statement of how the observer will be able to tell when the objectives have been attained.
TIME FRAMES:
Each objective or goal should have a deadline set for attainment. These time frames hold the staff to some expectation and mandate attention to the point of at least changing the time frame when it is not met.
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D1 Family Relationships Score this item for the youth’s family only. If there is not an identified family for the youth, answer no and go to question D2. If the youth does not have an identified family, particular attention is given to D11, After Care Living Situation in the assessment and service plan. Family is defined as the person(s) legally responsible for the youth; the legal parent or custodian of the youth. Family may include all persons who were a regular part of the household at the time of commitment. Relationship practices are the interactions between family members as guided and directed by adults.Does youth have an identified family? / Yes / No. if No, do not answer this question.
Family / +3 Consistent, positive relationship practices.0 Adequate relationship practices.-3 Inadequate relationship practices.-5 Destructive/abusive relationship practices.
+3 / Family consistently demonstrates positive and age appropriate relationship, communication, protection, and nurturing and social activities.
0 / Family demonstrates adequate and age appropriate relationship practices, supportive of treatment.
-3 / Family demonstrates inadequate relationship practices. Family members may visit, but are oppositional to treatment or not supportive of the treatment process.
-5 / Family demonstrates destructive and/or abusive relationship practices.
Explain the reason for scoring in the space provided.
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For the family, indicate which, if any, of the following behaviors or descriptions apply:Youth’s family is not supportive of Treatment / Youth’s family will impede treatment process
I. / Family Relationship Goal(s):
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A. / Objective(s):DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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B. / Time Frames:DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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C. / Indicators:DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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D2 Emotional Stability Score this item for the youth and family. The family score is based on any person in the family who displays a strength or need in the areas listed.Family / +3 Displays positive emotional coping skills.0 Displays appropriate emotional responses.-3 Periodic emotional responses.-5 Frequent emotional responses/severe limits.
Youth / +3 Displays positive emotional coping skills.0 Displays appropriate emotional responses.-3 Periodic emotional responses.-5 Frequent emotional responses/severe limits.
+3 / Displays ability to deal with disappointment, anger, grief in a positive manner: Expresses an optimistic view of personal future. Youth expresses empathy, shows concern for others.
0 / Displays appropriate emotional responses. Displays age appropriate emotional, coping responses. May demonstrate some depression, anxiety or withdrawal symptoms that are situationally related. Maintains situationally appropriate control.
-3 / Periodic or sporadic emotional responses which limit but do not prohibit adequate functioning such as aggressive acting out, withdrawal, mild symptoms of depression anxiety, neuroses, or need for Psychotropic medication.
-5 / Frequent or extreme emotional responses which severely limit adequate functioning. Definition includes incidents of suicidal gestures, need for mental health treatment, hospitalization, psychotropic medication, self-abusive behaviors or fire setting behavior.
Explain the reason for scoring in the space provided. If mental illness is checked, type in the diagnosis in the space provided.
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For the youth and family, indicate which, if any, of the following behaviors or descriptions apply:Family / Youth / Family / Youth
Suicide Documented Attempt(s) / Truancy/Escape (Placement)
Attempts within 1 year / What was the security level the escape
Attempts within 2 years / was from? / Low / OM / CM / H
Suicide Posturing/Gestures / Mental Illness (DSM)
Severe Mood Swings / Diagnosis:
Fire Setting (Gratification) / Diagnosis:
Fire Setting (Retaliation) / Dual Diagnosis
Fire Setting (Accidental) / Psychotropic Medication
Self Mutilation / A.D.H.D.
Active/Recent / Anti-depressant
Requires Professional/Medical / Anti-psychotic
Attention / Combination of Type
Truancy/Escape / Abuse of Animals
(Community Based) / Enuresis (related to emotional conditions)
Manipulation of Bodily Fluids
(smearing, etc.)
I. / Emotional Stability Goal(s):
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A. / Objective(s):DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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B. / Time Frames:DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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C. / Indicators:DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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D. / Individual(s) responsible:DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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D3 Substance Abuse Score this item for the youth and family. The family score is based on any person in the family who displays a strength or need in the areas listed. Information for scoring the item is determined through review of case file material, reports from police, reports from past assessments or treatment providers, interviews with the youth, family members or collateral’s.Any use of illegal substance(s) by the youth is problematic and must be addressed in the service plan for the youth. If the youth is scored –0-, substance abuse education services must at least be provided or documentation on past participation by the youth. If the youth scores -2 or –4 a referral for a substance abuse assessment and/or treatment must be provided.
Substance abuse includes disruption of functioning, as evidenced by such things as job loss, removal/dropping out of school, problems with the law, and/or physical harm to self or others. Determine the level of substance use and problems resulting from use by obtaining information in the following areas: frequency of use, planning for use, violent behavior while using, school issues, parental use, attempts to cut down or quit, blackouts or medical problems from use.
Indicate the specific type of substance(s) used/abused by the youth and/or family member. Treatment means an intervention designed to address substance abuse issues for the youth.
Family / +2 No use.0 Experimentation that does not affect functioning-2 Continued substance abuse.-4 Chronic use that limits daily functioning.
Youth / +2 No use.0 Experimentation that does not affect functioning-2 Continued substance abuse.-4 Chronic use that limits daily functioning.
+2 / No use by youth. No evidence of problematic substance use or use of illegal substances by family member(s). Family members understand negative consequences of substance use and verbally express opposition to substance use.
0 / Experimentation, occasional/infrequent use that does not cause problems in daily functioning. Substance use issues are admitted and willingness to seek treatment is exhibited or family members are currently in treatment.
-2 / Some substance use by youth and or family. Some substance use problems resulting in disruptive behavior, discord in relationships, and/or deterioration of functioning in school/work.
-4 / Chronic substance abuse that limits daily functioning. Denial of substance abuse problems. There has been failed attempts at rehabilitation and/or not presently involved in treatment, refusal of treatment and/or selling drugs. Problems resulting in serious disruption of functioning, such as loss of relationships, job, removal/dropping out of school, problems with the law, and/or physical harm to self or others, dependency.
Explain the reason for scoring in the space provided.
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For the youth and family, indicate which, if any, of the following behaviors or descriptions apply:Family / Youth / Family / Youth
Denial / Prior Treatment Failures
Refusal of treatment / Selling drugs
Describe substance use/abuse noted above by type (check all that apply, leave blank if none):
Youth Family / Youth Family / Youth Family
Cocaine / Amphetamine / PCP
Heroin / Marijuana/Cannabis / Inhalants
Alcohol / Prescription Medicine / LSD
Injects any substance / Cigarette Use
Other
I. / Substance Abuse Goal(s):
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A. / Objective(s):DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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B. / Time Frames:DHS-236 (Rev. 5-05) Previous edition obsolete. MS Word Page 11
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