bcal-3130-a, initial evaluation€¦ · sarah reese - r 345 963 983 009, expires 5/24/15, on file...

INITIAL FOSTER/ADOPTION HOME EVALUATION Michigan Department of Human Services

Bureau of Children and Adult Licensing Applicant(s) interested in:

Relative Assessment. If yes, please describe legal relationship:

Foster Care

Adoption AGENCY NAME: Adoptions for Michigan Children

AGENCY LICENSE NUMBER: 438723 Date of Report: 6/14/13

1. FOSTER/RELATIVE/ADOPTIVE HOME INFORMATION: Home name: Sarah Reese Foster home license number, (CF # or CG#): Address: 4562 Meadowbrook Rd, Benton Harbor, MI, 49022 Telephone number (s): 269-555-9865 Email address: [email protected] Driver’s license number/State ID number for all adult members of the household; verification of valid driver’s license:

Sarah Reese - R 345 963 983 009, expires 5/24/15, on file with agency Dale Jacobs - J 298 882 254 332, expires 2/14/16, on file with agency

MEMBERS OF HOUSEHOLD:

Name DOB Relationship to Caregiver Date of Placement

(if applicable) Sarah Reese 5/24/57 Applicant Dale Jacobs 2/14/40 Father of applicant

DIRECTIONS TO THE HOME:

From I-94W toward Chicago, take the Meadowbrook Exit. Turn Right Meadowbrook and head east. The home is located on the south side of the road.

SOCIAL WORK CONTACTS:

Date Persons Type of Contact/Place

03/12/13 Sarah, this worker Orientation

03/27/13 Sarah, this worker Office visit

04/22/13 Sarah, Dale, this worker HV

05/08/13 Sarah, Dale, this worker HV

2. BCAL CLEARANCES: For all Adult Members of the Household: Act 116, R.400.9201, R.400.9202, R.400.9205, R.400.9206)

Department of Human Services Office of Workforce Development and Training

Adoption 3130 Example 0614

Trai

ning

• Date of BCAL Criminal History Check for everyone 18 years and older: Results of Criminal History Check: Sarah had her fingerprints completed on 04/05/13. Results from her fingerprints show

that Sarah has no criminal history. Central registry clearances were received on 04/15/13. There is no criminal history. This worker performed an ICHAT on Sarah Reese on 03/27/13 and 05/10/13. There is no criminal history. Local clearances were received on 04/04/13. There is no criminal history.

Criminal History exists for named offense, PLACEMENT IS PROHIBITED if a member of the household has a felony conviction for the following crime(s):

1. Child abuse/neglect. 2. Spousal Abuse. 3. Crime against children (including pornography).

4. A crime involving violence, including rape, sexual assault or homicide but not including other physical assault or battery.

5. A physical assault or battery within the last five years. 6. A drug related offense within the last five years. Please explain:

Criminal History exists but does not prohibit placement. List all offenses. Describe the length of time since the

offense and the services completed that rectified the situation. Address safety risks and identify protective interventions. Assess rehabilitation:

Sarah's father, Dale Jacobs is currently living with her. This worker performed an ICHAT on 03/27/13 and 05/10/13. The following criminal history exists: 02/18/1987: Misdemeanor Weapons-Firearms-Safety Inspection Violation. 02/17/1989: Misdemeanor Operating-Impaired It has been 26 years from Dale's first criminal charge of a weapons safety inspection violation. It has been 24 years since Dale's criminal charge of operating-impaired. Dale is currently diagnosed with Vascular Dementia. He was unable to be interviewed regarding these criminal history charges. Sarah reports that she was unaware that her father had criminal history charges. She reports that there are no weapons in the home. There are no safety risks, as there are no weapons in the home, and Dale will not be responsible for caring for an adopted child. Dale did not share this conviction with Lutheran Adoption Services; however, due to Dale's diagnosis of dementia, this worker understands the reasons why Dale was unable to share this information with her. This worker does not have any concerns regarding Dale's criminal history. This worker does not have any concerns regarding an adopted child being placed in Sarah's home, where Dale currently resides. Sarah signed the Weapons Policy on 03/26/13 stating that there are no weapons in the home. This worker received local clearances on 04/22/13. Local clearances show that Dale does not have any criminal history in Berrien County. Central registry clearances were received on 05/09/13. Central Registry clearances show that Dale is not listed on central registry. Central clearances show that the criminal history that exists is consistent with what is reported above.

The CPA must have the written approval of BCAL to recommend original licensure if there are any pending criminal charges.

CENTRAL REGISTRY: Michigan Date of Central Registry Check: 04/15/13, 05/09/13 Has applicant lived in any other states in the last 5 years? Yes No If yes, identify what states the person lived in. There must be a central registry clearance from that state.



Trai

ning

Central Registry Results: N/A: Not found Yes, there is a history of child abuse or neglect.

a. Describe the length of time since the substantiation and any services that have been provided to rectify the concern.

N/A b. Address any risk factors that might impact the safety of the child and describe what protective interventions

are in place currently. N/A *If there is any household member who is on Central Registry, THE HOME CANNOT BE LICENSED. Are there any rules that are in non-compliance? Yes No If Yes, list all rules and headings: Willful Substantial Supporting documentation: ART: Yes No 3. COMMUNITY: Type of community (rural, urban, etc.):

Sarah resides in the urban city of Benton Harbor, Michigan. Benton Harbor is located in Berrien County, the southwest corner of Michigan. The neighborhood consists primarily of small to moderate single family homes. The nearest larger cities are Kalamazoo and St. Joseph. Sarah describes her community as being urban.

Socio-economic makeup:

Benton Harbor can be described as a low to working class neighborhood. Local school data reports that 89% of students in the Benton Harbor school district are eligible for free or reduced price lunch compared to the national average of 42%.

Racial/cultural makeup:

The racial and cultural makeup of Sonia's community is primarily African-American. According to local census data the population make-up is: 97% African-American, 2% Caucasian, <1% Hispanic and <1% Asian/Pacific Islander.

Availability of recreational facilities:

There are several recreational facilities within a short distance of Sarah's home. Jean Clock Park is a park with a beachfront by Lake Michigan. It also has open and wooded sand dunes. There are also several beaches that are close to Sarah. Silver Beach, Tiscornia Beach and Lions Beach all offer playground equipment, grills and a picnic area. Union Park offers lighted baseball and softball fields and basketball courts. This park also offers playground equipment and a picnic area. There is also the Boys and Girls Club of Benton Harbor, Lakeshore Roller Rink, and Celebration Cinema movie theater within a short distance of her home. Sarah reports that she is not involved in specific community organizations; however, Sarah is familiar with organizations, activities, and recreational facilities located in Berrien County.

School system, including special education:

Sarah resides in the Benton Harbor school district. The nearest schools are Countryside Charter, Sorter Elementary School, Fairplain Middle School and Benton Harbor High School. These schools have the willingness and ability to provide special education services to an adopted child if needed. Sarah reports that an adopted child placed in her home would attend Countryside Charter School. Countryside Charter is three miles away from Sarah's home, and has the availability of special education services if needed.



Trai

ning

Hospitals and medical care, noting facility utilized by family:

The following hospitals are located near Sarah's home: Lakeland Medical Center - St. Joseph - 4.4 miles away from home 1234 Napier Avenue St. Joseph MI 49085 Lakeland Medical Center - Niles - 23.46 miles away from home 31 N. St. Joseph Avenue Niles MI 49120 Sarah identifies Lakeland Medical Center - St. Joseph as her hospital of choice. She utilizes Intercare in Benton Harbor for health care needs. Sarah reports that she will utilize Intercare for health care needs for an adopted child. The local fire and police station in Benton Harbor are located within one mile from Sarah's home.

Availability of churches, noting family’s choice of church:

There are several churches available near Sarah. Sarah identifies her choice of church as being Napier Parkview Baptist Church, located in Benton Harbor. The following churches are also located near Sarah: Greater Community Church, Pilgrim Rest Baptist Church, Fairplain Presbyterian Church, and St. Bernards Catholic Church. Sarah reports that she is willing and able to accommodate the specific religious needs of any child placed in her home.

4. DESCRIPTION OF HOME: (R.400.9206, R.400.9301, R.400.9302, R.400.9303, R.400.9304, R.400.9305, R.400.9306, R.400.9307, R.400.9308, R.400.9309, R.400.9401, R.400.9410, R.400.9411, R.400.9414, R.400.9418, R.400.9419)

Description of home and all rooms, noting condition, layout, appearance: (Does the home meet the minimum level of cleanliness necessary to meet the needs of the child to be placed? If not, is the applicant taking action to address the home’s deficiencies?)

Sarah lives in a 3-bedroom ranch-style home with an attached 2-car garage. Her home sits on 2.5 acres. There are three bedrooms and one bathroom. When you enter the front door, you walk into a sun-room/screened in porch area. To your right there is a door that leads into the main area of the home. After you walk through the door, in front of you sits the living room. The living room is very large and adequate for play space. Walking across the living room, bedroom #1 is straight ahead. This is where an adopted child will sleep. To your left, there is a small hallway. On the right-hand side of the hallway there is a bathroom. Bedroom #2 is on your left-hand side. This is where Sarah sleeps. Beginning at the living room again, to your left-hand side there is a small hallway and bedroom #3. This is where Dale sleeps. Straight ahead is the kitchen area, along with a dining area that has a kitchen table and chairs. In the back of the kitchen there is a sliding glass door that opens to Sarah's backyard and deck. Sarah's backyard is fenced in, and can also be utilized for play space. This worker has assessed Sarah's home and it appears to be in good condition. All of the bedrooms are in good condition and there are no concerns observed. Sarah's home meets the minimum level of cleanliness necessary to meet the needs of a child. Sarah's home does not have any deficiencies.

Description of play space:

Sarah has a large living room that can be used for play. A child can also use his or her bedroom as a play area. Sarah also has a spacious backyard that can be used for play as well.

Safety considerations, including weapons or pets: • Are there pets in the home? Yes No Does the pet have current vaccinations? Yes No • Is the pet friendly or is the pet a safety concern? (Explain what makes the pet a friendly or a safety concern. Describe how does the pet interacts with others.)



Trai

ning

Sarah does not have any pets. • Is the pet well cared for? Yes No

• Are there any water hazards on or near the premises? Yes No If yes, describe how the caregiver plans to safeguard children around them.

There are no water hazards on or near Sarah's home. Sarah does not live on a lake or river, and there are no water safety concerns. This worker does not note any additional property risk factors.

• Are there working smoke detectors on each floor and between each sleeping area and the rest of the home? Yes No • Is there a working carbon monoxide detector installed as recommended by the manufacturer? Yes No

Sarah has working smoke detectors between each sleeping area and the rest of the home. There is a smoke detector located in the hallway in between the bedrooms and the kitchen. Sarah has a working carbon monoxide detector located in the kitchen.

• Are there weapons in the home? Yes No If yes, describe type and how stored. Weapons must be trigger locked and locked in a place separate from ammunition.

Sarah does not have any weapons. She signed the Weapon's Policy on 03/26/13. A copy is located in her family file.

• Where are medications stored?

Sarah reports that she keeps her medications on the top shelf of a kitchen cabinet. A child would not be able to reach this shelf.

Explain the proposed sleeping arrangements for family members and foster/adoptive children.

Bedroom #1 is where an adopted child will sleep. This worker measured the bedroom on 05/08/13. Bedroom #1 measures at 8 feet by 10 feet. There is one twin size bed in this room at this time. Bedroom #2 is where Sarah sleeps. This worker measured the bedroom on 05/08/13. Bedroom #2 measures at 14 feet by 20 feet. There is one King size bed in this room. An adopted child would not sleep in this room. Bedroom #3 is where Dale sleeps. This worker measured the bedroom on 05/08/13. Bedroom #3 measures at 12 feet by 14 feet. There is one King size bed located in this room. An adopted child would not sleep in this room.

Do all bedrooms have a window and a door than can be used to get out of the house in an emergency? Yes No If “NO”, please explain:

All bedrooms have a window and a door that can be used to get out of the house in an emergency.

Are there people sleeping in other rooms in the home? Please describe.

There are no other people sleeping in other rooms in the home aside from Sarah, and her father Dale Jacobs.

Water, sewer, refuse arrangements, health inspection results if applicable:

Sarah reports that her water, sewer, and trash services are handled by the city of Benton Harbor. There have been no health inspections.

Water temperature tested 120o Fahrenheit or less? Yes No

This worker tested the water temperature on 05/08/13. The water temperature tested at 119 degrees Fahrenheit.

Emergency procedures information completed:

In the event of an emergency the family has access to a meeting area outside of the home. Sarah has a front yard where the family would be able to meet outside in the event of an emergency. Sarah also lives near the local community college, and if needed, the family could meet in front of the college. Both areas would be sufficient meeting areas in the



Trai

ning

event of an emergency.

Adequacy of the house, property, neighborhood, schools and community for the purpose of fostering/adopting as determined by on-site visits:

This worker conducted two on-site visits to Sarah's home on 04/22/13 and 05/08/13. Sarah's home and property are appropriate and suitable for an adopted child. Sarah's home is well-kept, clean and organized. The neighborhood that Sarah lives in has been assessed and presents appropriate for an adopted child. The schools within the Benton Harbor school district have special education services available should an adopted child need them. There are many things to do around the Benton Harbor area. There are many restaurants to go out to eat, a local movie theater; family parks, bowling alleys, and a small mall are located within minutes from Sarah's home. There is also Lake Michigan and several beaches located in the neighboring town to Sarah. The home, property, neighborhood, schools, and community are appropriate for an adopted child.

Means of transportation; i.e. ages and makes of automobiles, reliability, proof of insurance on each vehicle, availability of required safety seats for young children, accessibility of public transportation if needed:

Sarah owns her vehicle and does not make auto payments as it has been paid in full. Sarah drives a 2005 Chevy Cruze. Sarah states that her vehicle has been very reliable. Sarah has the required safety seats for young children. Sarah has access to Dial-A-Ride as a form of public transportation if needed. Sarah has State Farm insurance as her form of auto insurance, and a copy of her auto insurance is located in her family file.

DESCRIBE PLANS FOR DAY CARE AND/OR SUBSTITUTE CARE. (R400.9403(d)(ix), R400.9412)

Sarah reports that she will utilize her mother, Hattie Ray as her day care provider for an adopted child, if child care is needed. Sarah displays an appropriate level of stability and maturity. She has identified her daughter, Jackie Gaines as her alternative caregiver for n adopted child. Jackie currently resides in Atlanta, Georgia. Though Jackie does not live in the immediate area, Jackie is able to visit when she comes to Michigan. Jackie is 37 years old. She is in good physical, mental, and emotional health. She does not have a history of substance abuse, and does not have a criminal or CPS history. This worker interviewed Jackie on 05/07/13. Jackie states that she feels positive about being identified as an adopted child’s alternative caregiver, and that she is more than willing to be involved that child’s life. She states that she is always willing to be there for her family; though Jackie lives a bit farther away at this time, she makes a positive effort in visiting with an adopted child as often as she can. She states that she would "step-up and do what needs to be done" if something were to happen to Sarah where an adopted child would need an alternative caregiver. Jackie signed the Alternative Caregiver Statement on 04/10/13, and a copy is located in Sarah's family file.

Are there any rules that are in non-compliance? Yes No If Yes, list all rules and headings: Willful Substantial Supporting documentation: Variance requested? Yes No

5. FINANCIAL: (R.400.9201, R.400.9206) Date family provided with information of Ineligible Grantee Funds, Medicaid, Food Stamps, WIC in DHS Pub 457 for

children in relative care: This does not apply to Sarah Reese. Source of income, how this was verified, stability of income, how expenses were verified. Does the family have a plan for

any known financial changes that may occur in the future i.e., unemployment payments ending, cash assistance ending? Department of Human Services Office of Workforce Development and Training


Trai

ning

Sarah is employed full-time outside of the home as an accountant. She is employed by a hotel located in Benton Harbor. Sarah earns approximately $2,100 per month from her job, and she presents as financially stable. A copy of her paystub is located in her family file as a verification of income. Sarah's father Dale currently resides with her. Dale earns Social Security Income as his form of income; he earns $992 per month in SSI payments. Dale earns SSI due to his age and retirement. A copy of Dale's SSI statement is located in Sarah's family file. Sarah does not have any known financial changes that may occur in the future, such as unemployment payments ending, cash assistance ending etc. Sarah has access to a savings account where she is able to utilize that money for any emergencies or unexpected financial changes.

If income is based on disability, i.e. SSI, Social Security Disability, long term disability payments from a job, workmen’s

compensation, etc., describe the verification of the physical or mental disability and an assessment of how that impacts the ability to provide foster/adoptive care or be a member of the household.

This does not apply to Sarah Reese. If child support payments are ordered, are the payments being made and are they current? If there are arrears, how much

and what is the plan to bring the payments current? How was this verified? This does not apply to Sarah Reese. Detail a financial statement that specifies the amount of net income for the household and identifies all ongoing and

routine bills and expenses including, but not limited to, housing (mortgage or rent, insurance, property taxes), utilities, food, clothing, transportation (car payments, insurance, fuel), credit cards, student loans, contributions to religious organizations, savings contributions, etc.

Sarah reports that she is employed full-time outside the home as an accountant. She is currently employed by a hotel in Benton Harbor. Verification of her income is located in her family file. Sarah's take-home earnings from her job per month are $2,100. Sarah's father Dale also currently resides with her. Dale receives Social Security Income due to his age and retirement. Dale receives $992/month from SSI. Verification of Dale's SSI payments are located in Sarah's family file. Sarah reports that her monthly expenses are the following: Housing: $0 Utilities: $550.00 Telephone: $138.00 Groceries: $200.00 Auto Payments: $0 Auto Expenses: $140.00 Auto Insurance: $70.00 Clothing: $varies Credit Cards: $0 Student Loans: $0 Church: $100.00 Recreation: $100.00 Medical/Life Insurance: $91.00 Total Monthly Expenses: $ 1489.00 After paying all of her monthly bills and expenses, Sarah has approximately $1511 left over. Sarah appears to manage her finances appropriately. It should be noted that Dale is responsible for paying the housing expenses. Sarah reports that the housing expenses are $198.00 per month. She states that Dale uses the money that he receives from SSI to pay the housing bill. Sarah is not responsible for paying any other monthly expenses that are not listed above.



Trai

ning

Assess the family’s money management skills and ability to meet their needs with their current income. Is the family current on their bills? Can the family meet the financial expenses of having a relative/foster child placed in their home prior to payment starting?

Sarah is able to meet all of her monthly financial obligations of having an adoptive child placed in her home prior to receiving any adoption subsidy payments. She appears to be financially stable, and some of her expenses vary from month to month (utilities, groceries etc.) allowing her to have a greater income some months after all expenses are covered. Sarah does not report any upcoming financial changes and she does not have a specific plan in place for any unexpected financial changes. However, Sarah has demonstrated that she is a responsible and resourceful individual. She is able to use any extra money that she has left over in the month for any financial emergencies that may arise. Sarah reports that her medical insurance carrier is Blue Cross/Blue Shield. She receives this insurance from her employer. Sarah reports that she plans for an adopted child to continue utilizing their individual Medicaid plan for medical insurance.

Are there any rules that are in non-compliance? Yes No If Yes, list all rules and headings: Willful Substantial Supporting documentation: Variance? Yes No

6. SOCIAL HISTORY: (for each adult member of the household, including adult children who live in the home) (R.400.9201, R.400.9202, R.400.9206)

Descriptive information: Age, height, weight, hair color, nationality, race or ethnicity, place of birth. American Indian heritage must be consistent with information on the BCAL-3889 and the BCAL-0120-A. Family of origin description. Include:

Number of siblings, parents’ roles, personalities, expectations, parenting involvement, styles, values. Relationship with each parent and siblings (if any) growing up and now. Parents’/primary caretakers’ childrearing techniques, including discipline. How family dealt with losses. Describe family celebrations. Parents’ substance use and how it affected the family, lasting impact on individual. How family dealt with any abuse or victimization issues, continuing impact on individual. Role of religion in the family. Other significant influences when a child, e.g. grandparents, step parents, aunts, uncles.

Sarah Marie Reese was born on 05/24/1957 in Chicago, Illinois. A copy of her birth certificate is located in her family file. She is a 55 year old African-American female. Sarah is 5'8" tall and weighs 170 pounds. She has brown eyes and black hair. Sarah identifies her nationality, race and ethnicity as African-American. Sarah does not wear glasses and does not have any visible identifying marks or scars. Sarah was born in Chicago Illinois to her parents Hattie Ray and Dale Jacobs. She is the oldest child, and has one sister and one brother. Sarah's siblings are: Leslie Sims, age 44. Leslie currently resides in Kansas City, Missouri. Sarah describes her relationship with Leslie growing up as positive. She states that she is 10 years older than Leslie, and always looked after her. Sarah reports that her relationship with Leslie today continues to be positive. She states that she and Leslie talk regularly and are able to visit one another occasionally. She states that they never miss the opportunity to say "I love you". Jerome Franklin, age 47. Jerome currently resides in Kansas City, Kansas. Sarah describes her relationship with Jerome while growing up as positive. She reports that she was a bit older than Jerome and always looked after him while growing up. She reports that her relationship with Jerome today continues to be positive. Sarah reports



Trai

ning

that she and Jerome talk regularly and are able to visit one another occasionally. Sarah reports that they never miss the opportunity to say "I love you". Sarah reports that her parents were never married to one another while growing up. She states that she never saw them together as a couple. Sarah states that she lived in Chicago with a close family that consisted of mostly women, as her grandmother also resided with them. She reports that her father resided in Benton Harbor, MI and that she was unable to have much of a relationship with him due to the distance between them. She states that they spoke regularly, but did not spend that much time together until she moved to Benton Harbor. Sarah states that she moved to Benton Harbor Michigan when she was 11 years old. She states that her relationship with her mother while growing up was positive, stable, supportive, and respectful. Sarah reports that her relationship with her mother today is fantastic. She reports that she talks with her mother daily. Sarah reports that her relationship with her father growing up was loving and affectionate, yet also distant. She reports that they did not become close with one another until her pre-teen and teenage years. Her relationship with her father today is very positive, and her father currently resides with her. She states that her father's health has begun to deteriorate and that she takes care of him. Sarah describes her mother's personality as tough and loving. She describes her father's personality as laid-back. Sarah reports that her extended family was always close to one another and that she considers a variety of her extended family members to be significant relationships in her life while growing up. Sarah reports that her parents were very respectful to one another while growing up. She states that they still talk on a semi-regular basis with one another. She describes their parenting styles as hard-working and loving. She states that family values included the following: respecting others, responsibility, honesty and integrity. Sarah reports that her parents expected she and her siblings to grow up with these same values. Sarah reports that these same values are what she tried to instill in her own children today. Sarah reports that family traditions included having Fourth of July cookouts and fireworks, and Christmas dinners. She states that holidays and birthdays are always celebrated and these are traditions that her own family has continued today. Sarah states that her overall quality of life while growing up was excellent. She states that she had everything she needed, and learned to work for what she wanted. She states that her life was full of strong women who taught her life skills and respect. Sarah reports that as a child she was disciplined by spanking, lectures, yelled at, groundings, and the removal of privileges. Sarah states that she feels that the discipline that she received as a child was not always fair and consistent. Sarah reports she disciplined her children by talking with them, removal of privileges, positive reinforcement, lectures, and groundings. Sarah reports that her family also valued religion and attending church. She states that she attended a Baptist church while growing up and was involved in church activities and functions. Sarah states that religion was used to reinforce positive behavior and also explain the unknown. Faith continues to be a strong value for Sarah, and she has tried to instill the same value of faith in her own children; Sarah continues to attend a Baptist church in the Benton Harbor Michigan area. Sarah seems to have positive memories regarding attending church while growing up, and religion continues to play an important role in her life today. Sarah reports that she has never dealt with any abuse or victimization issues. She denies any history of domestic violence within her family. Sarah reports that her family did not struggle with any substance use issues.



Trai

ning

Dale Jacobs was born on 02/14/1940 in Benton Harbor, Michigan. He is a 73 year old African-American male. A copy of his birth certificate is located in Sarah's family file. Dale is 5'10" tall and weighs 180 pounds. He has brown eyes and black hair. Dale identifies his nationality, race and ethnicity as African-American. Dale wears glasses, and he does not have any identifying marks or scars. Dale is Sarah's father and he currently resides in the household. It should be noted that Dale is diagnosed with Vascular Dementia; therefore, this worker was unable to complete a full social history for him. This worker relied on answers from Sarah regarding Dale's social history. Dale was born to his parents Henry and Martha Jacobs. He reportedly had two sisters and one brother. His siblings are: Gerald Washington. Gerald reportedly passed away in 2005. Sarah states that Dale and his brother were close to one another while growing up, and continued to be close with one another while they were adults. She believes that Dale had a positive relationship with his brother. Lilly Horne. Lilly reportedly passed away in 2010. Sarah states that Dale and his sister were close to one another while growing up. She states that she believes they continued to be close to one another while they were adults. She believes that Dale had a positive relationship with his sister. Monique Smith. Monique reportedly passed away in 2012. Sarah states that Dale and his sister were close to one another while growing up. She states that she believes that they continued to be close to one another while they were adults. She believes that Dale had a positive relationship with his sister. Sarah reports that Dale's parents were married while he was growing up, and that he had a positive relationship with them. Sarah states that she spent a lot of time with her grandparents while she was growing up as well when she was very young. Sarah reports that both of Dale's parents passed away at an early age; she states that Martha passed away at the age of 55, when Sarah was approximately 6 years old. Sarah states that Henry passed away approximately four years later, when Sarah was approximately 10 years old. Sarah was unable to describe their personalities, as she was very young when her grandparents passed away. Sarah reports that she believes Dale's overall quality of life while growing up was "good". Sarah reports that Dale has a history of military services. She states that Dale was enlisted in the Army for eight years. He was then a police officer for the city of Jackson for ten years. This worker spoke further with Sarah regarding the care that Dale requires from her. Sarah states that she handles her father's "business", meaning that she has Power of Attorney for him and aids him in the financial aspects of his life. She reports that she also cooks for him and washes/cleans his laundry. Sarah states that she also maintains their home; however she notes that this is something that she would do even if her father was not living with her. Dale has a home-health nurse that comes to the home on a monthly basis to see how he is doing physically, and if there are any medical needs. Sarah reports that caring for her father does not demand a significant amount of time to where she would be unable to care for a child. Sarah reports that her father will enter a skilled nursing facility that would be better able to meet his needs if his health



Trai

ning

deteriorates to the point where she would no longer be able to care for him. Any history of out of home care? This should include any history in non-court-ordered out of home care. Educational history and any special skills and interests:

Employment history – If the person does not have an employment history or there are large gaps in the employment history, explain how they were supported during that period of time:

Relationship history – Significant relationships prior to current one; how they ended; if previously married, whether divorce has been obtained or considered and whether there is verification.

Sarah denies any history of out of home care, which includes non-court ordered out of home care. Sarah attended Chicago public schools until moving to Benton Harbor, Michigan in 1969. Sarah attended Benton Harbor High School while growing up. She reports that she got pregnant when she was 14 years old and dropped out of school when she was 16. Sarah then earned her GED at age 19. Sarah reports that she was an exceptional student prior to dropping out, and that she was double promoted from 5th grade to 7th grade. Sarah reports that she was not involved in any clubs, sports or organizations while in school. Sarah reports that she attended Baker College in 1984-1985 to study Marketing. Sarah did not earn her degree. She then attended a local Community College from 1977-1978 to study Human Services. Sarah did not earn her degree. Sarah reports that her previous employment is the following: 2000-2005: Sarah reports being employed as a Property Manager in Benton Harbor, Michigan. 2005-2009: Sarah reports being employed at a florist as a manager in Benton Harbor, Michigan. 2010-2012: Sarah reports being employed by Learn and Grow Childcare Center as a child care provider. 2011-Current: Sarah reports that she is currently employed as an Accounting Assistant at Sheraton Hotel. Sarah has been employed at Sheraton since April 2011. Sarah has been married one time. Sarah reports that she was married to Sam Jacob Reese on 05/22/1983. She reports that she divorced Sam because he was abusive. Sarah states that she divorced Sam in 1994. A copy of her marriage certificate and divorce decree is located in her family file. Sarah reports that there was a history of domestic violence within this relationship. Sarah reports that she talked with her pastor and received counseling. She reports that she began receiving counseling after her divorce, and that she participated in counseling for approximately 6 months. Sarah does not have any children from her marriage with her ex-husband. Sarah's first serious relationship was with Lawrence Franklin. Sarah reports that she and Lawrence were best friends with one another. She states that they grew apart as a couple, but have always remained friends. Sarah and Lawrence had one child together, Sarah's daughter, Janessa. Sarah reports that she and Lawrence continue to maintain contact with one another, and that Lawrence is still a very involved parent. She reports that she invites Lawrence to be a part of family gatherings, activities etc. She and Lawrence have continued to maintain a positive relationship with one another. Lawrence will not have any parental involvement with an adopted child. Sarah's next serious relationship was with Mitchell Simmons. She states that she and Mitchell met at work and began dating. She reports that they dated one another for approximately 7 years before ending their relationship. Sarah reports that the relationship ended because he was emotionally abusive. Sarah states that she was not used to having a man speak to her the way that Mitchell did, and that ultimately this is what led to their relationship ending. Sarah had three of her children from this relationship, her daughter's Jackie (age 36) and Jenna (age 33), and her son Jeremy (age



Trai

ning

31). Sarah states that Mitchell was a great father to her children and that she continues to talk with him today. She reports that Mitchell has always been involved in her children's lives, and that he is always invited to family gatherings when they have them. Sarah's next serious relationship was with Daniel Little. She states that Daniel was friends with her cousin, and this is how they met. She states that she and Daniel dated for approximately 3 years before ending their relationship. Sarah states that their relationship ended simply because they grew apart. Sarah had one child from this relationship, her youngest daughter Jennifer. Sarah reports that her relationship with Daniel continues to be positive today, and that he is also invited to family gatherings and activities. Dale was unable to discuss his history with this worker, however, Sarah was able to report some additional details. Dale was never placed in out of home care as a child. Dale graduated from high school and entered into the military. Sarah states that Dale was enlisted in the Army for eight years. He was then a police officer for the city of Jackson for ten years. Sarah was unsure of what his interests and special skills were when he was in school. Sarah was unaware of any gaps in Dale’s employment. When he retired from the police force, he began working in a security position at the courthouse. Dale worked in that role until he left the workforce. Sarah was not aware of Dale’s relationship history other than his involvement with her mother, Hattie Ray. Dale and Hattie never married, but had three children together.

Any children from previous relationships. Yes No Note any history of involvement in domestic violence, including as a victim, or absence of history:

Sarah reports that she was the victim of domestic violence within her marriage. Sarah states that her ex-husband was abusive to her and this is why she divorced him in 1994. Sarah states that she refused to be the victim in the relationship and that she has moved on. She also states that she sought counseling from her pastor during this time to aid her in coping with her experiences of domestic violence. The domestic violence that Sarah experienced within her marriage does not have a negative effect on her today. Sarah was not aware of any domestic violence involvement in Dale's past. She never witnessed any issues between her parents.

Description of personality, personal goals, hobbies, interests

Sarah describes her personality as fun, proactive, and assertive. She identifies her hobbies and interests as church, fishing, cooking, and gardening. Sarah describes her personal goals as being able to adopt a child. Sarah described her father Dale as very laid back. He enjoys fishing and reading books. Sarah would describe her father's personal goals as to live out the rest of his life as comfortable as he can.

Strengths and weaknesses, worker’s assessment in addition to what the applicant tells you:

Sarah identifies her strengths as budgeting, cooking, organizing and helping people. Sarah identifies her weaknesses as sweets and cookies. This worker identifies Sarah's



Trai

ning

strengths as being an organized, hard-working, and open individual. Sarah has complied with all of the requirements necessary in order to write this assessment, and she has completed all of the paperwork and requirements in a timely manner. This worker identifies Sarah's weaknesses as working full-time outside of the home; this worker understands Sarah's need and personal motivation to work outside the home, however a child that is not of school-age will need to be supervised by a daycare provider while Sarah is at work. This worker was unable to assess Dale's strengths and weaknesses due to the fact that he has dementia and was not really able to engage in a lengthy discussion with this worker.

Are there any rules that are in non-compliance? Yes No If Yes, list all rules and headings: Willful Substantial Supporting documentation:

7. FAMILY LIFE: (R.400.9201, R.400.9202, R.400.9206, R.400.9405, R.400.9418) Marital and family status and history, including current and past level of family functioning and relationships and any

incidents of domestic violence: Current relationship. Include: Brief history, including date and place of marriage, if applicable. Any history of infertility and how that has been dealt with. Any history of separations or domestic violence. Strengths of relationship, areas of work or attention. Common/shared interests or lack thereof. Roles, division of labor, decision-making process, handling stress or disagreements. Assess level of satisfaction, stability. Describe relationship w/parent of children if separated.

Sarah denies a history of infertility. She has had one separation in her relationship history, as she was divorced in 1994. Sarah does not have any children with her ex-husband. Sarah reports that she did experience some domestic violence issues within this relationship. Sarah reports that she sought counseling from her pastor during this time, and that she has moved on. The domestic violence that Sarah experienced within this relationship does not appear to have a negative effect on her today. Sarah reports that she is currently in a dating relationship with Ron Waters. They are not married to one another and they do not live together. She reports that their relationship is unique because they have known each other and been family friends for the majority of their lives. Sarah reports that Ron's strengths are that he is mature, shows responsibility, is a gentleman, and is great with her father. Sarah identifies Ron's weakness as that he has a back injury that prevents him from doing what he wants on occasion. Ron does not currently live in the home. Ron is aware of Sarah's plans to adopt and is very supportive of her decision. Sarah appears to be in a stable relationship and appears to be satisfied with her current relationship. Sarah does not have any plans to get married or to have their living arrangements change in the near future. Sarah is unable to report their roles, division of labor, and decision-making process as they are not currently living together, and they have no plans to live together in the near future. Sarah and Ron do not have any children together.

Family:



Trai

ning

Activities, goals, values, role of religion, church involvement:

Sarah reports that her family goes to the park together, out to eat with one another, or that they will just stay at home and spend time together. Sarah reports that religion plays an important role in her life and that faith is a value that she hopes to instill within an adopted child. Sarah is very involved with her church and her church seems to be a positive resource for her. Sarah reports that her goals include being able to adopt a child and to raise him or her in a positive environment.

Challenges, stressors, any history of help-seeking:

Sarah reports that her challenges and stressors at this time are working on cleaning up the basement in her home. She reports that the basement in the house flooded a couple of weeks ago and that she has been dealing with the insurance company to resolve the issue and make the necessary repairs. This can be stressful at times, however Sarah does not feel like this is a stressor or challenge that she cannot handle. Sarah reports that she relies on her faith as well as her family and friends during times of stress.

Losses and how dealt with:

Sarah reports that she has experienced the loss of her great-grandmother and grandmother in her life. She reports that she relied on the support of her family and friends during this time. Sarah appears to utilize positive coping skills during difficult times in her life.

Expected impact of fostering/adopting on all members of the household:

Sarah states that she expects for adoption to make a positive impact on the members of her household. Sarah expects that there will be an initial adjustment period in the home, but that everyone will become comfortable over time. Sarah reports that she expects for adoption to be positive for Dale, as he seems to enjoy interactions with children. Sarah does not spend a significant amount of time caring for Dale to where it would affect her ability to parent an adopted child.

Any individuals other than children of applicants currently living with the family, impact of those individuals on family functioning.

There are no other individuals living in the home at this time.

8. CHILDREN: (R.400.9201, R.400.9202, R.400.9206, R.400.9404, R.400.9407) All children must be interviewed/observed apart from the parents, even adult children no longer living in the home, or the

agency must note all attempts to contact them. If unsuccessful, the applicant’s explanations as to why you were unable to contact them.

For each child living in the home including relatives/foster children:

Identifiers: name, birth date, race (if different from parents’) school and grade, and/or employment. Date of placement for children already placed in the home (relatives).

Parents’ description of child’s personality, interests, activities. General adjustment, note if any involvement with law enforcement or the criminal justice system.

Worker’s assessment of child’s adjustment, development, special needs, relationships with parents and their significant others, and other strengths and weaknesses.

Child’s ideas and attitudes about fostering/adopting based on interview with the child. Child’s description of the discipline techniques used in the family. There are no children currently living in the home. For children who are grown and/or out of the home: Identifiers: name, age, where living, marital status. School and/or employment. General adjustment: note if any problems with law enforcement or the criminal justice system. Their opinion of their parents’ parenting skills and of their desire to foster/adopt children. Description of the discipline techniques used when they were a child.



Trai

ning

The willingness of the adult child to provide substitute care, if appropriate, or be involved with the foster/adopted children who may be placed into the home.

Any ongoing reliance by the adult child on the applicant for child care, monetary assistance, etc.

Sarah reports that she has five children. Her children are: Janessa L. Franklin, age 40. This worker spoke with Janessa on 04/09/13. Janessa is Sarah's oldest daughter. Janessa is not married and does not have any children. Janessa currently resides in Benton Harbor, Michigan. Janessa presents as well-adjusted in her life; she has not had any problems with law enforcement or the criminal justice system. Janessa reports that she is not currently employed and that she is searching for a job right now. Though Janessa is currently unemployed, she does not have any ongoing reliance on Sarah for monetary assistance. Janessa also does not have any children, and therefore does not rely on Sarah for child care needs. Janessa reports that Sarah is a great mother and has very good character. She states that Sarah is very hard-working and has always provided for her family. Janessa states that she and her mother talk to one another at least once per day, and that they socialize with each other every weekend. Janessa is very supportive of her mother's decision to adopt. Janessa plans to have daily interactions with an adopted child. She is more than willing to provide substitute care and be involved in his or her life. Janessa reports that she was disciplined by being sent to her room and the removal of privileges while growing up. She states that she feels this discipline was appropriate. Janessa does not have any mental health issues. She also does not have any substance use/alcohol abuse. Jackie M. Gaines, age 36. Jackie is Sarah's second oldest daughter. Jackie is currently married and has three children. Jackie resides in Atlanta, Georgia. Jackie presents well-adjusted in her life and reports that she does not have any problems with the law or criminal justice system. Jackie also does not have any ongoing reliance on Sarah for child care, monetary assistance etc. This worker spoke with Jackie on 05/07/13. Jackie reports that she is currently employed at Georgia Tech. Jackie is an Assistant Women's Basketball Coach. Jackie identifies her mother's greatest strengths as being a great mother and always providing for the family. She also states that she views her mother as a "Super-Mom". Jackie states that her mother's greatest weakness was the fact that she was a working mother while growing up. Jackie states that she and her mother talk regularly on the phone and visit with one another a few times per year. Jackie considers her mother to be one of her best friends. She states that she is planning on coming to visit at the end of this month for two weeks, and is very excited to see her. Jackie reports that she was disciplined by the removal of privileges while growing up, and that she feels that this type of discipline was appropriate. Jackie is also the alternative caregiver for an adopted child; Jackie states that she feels positive about being identified as the alternative caregiver, and that she is more than willing to be involved in an adopted child’s life. She states that she is always willing to be there for her family; though Jackie lives a bit farther away at this time, she makes a positive effort in visiting as often as she can. She states that if she would "step-up and do what needs to be done" if something were to happen to Sarah where an adopted child would need an alternative caregiver. Jackie is very supportive of Sarah's efforts to adopt, and she does not have any concerns regarding Sarah's ability to parent a child. Though she is unable to provide substitute care on a daily basis due to the distance, she is willing to provide substitute care in the event of an emergency. Jackie does not have any mental health issues. She also does not have any substance use/alcohol abuse.



Trai

ning

Jenna W. Franklin, age 33. Jenna is Sarah's third oldest daughter. Jenna is not married, and has four children. Jenna currently resides in Benton Harbor, Michigan. Jenna reports that she is not currently employed. She states that she was laid-off from her job with Chicago Cab Company and recently moved to the area. Jenna reports that she was employed with Chicago Cab Company for approximately 6 years before being laid-off. Jenna presents well-adjusted in her life and does not have a history of problems with the law or the criminal justice system. Jenna reports that she identifies her mother's greatest strengths as being a great mother. She is unable to identify any weaknesses. Jenna states that she is close with her mother today and that they talk on the phone regularly. They also see one another on weekends. Jenna reports that she was disciplined by the removal of privileges such as not being able to go out with friends or talk on the telephone while growing up. She is very supportive of Sarah's efforts to adopt a child and does not have any concerns regarding her ability to parent a child. Jenna does not have any mental health issues or substance use/alcohol abuse. Jenna also does not have any ongoing reliance on Sarah for child care or monetary assistance. Jeremy A. Franklin, age 31. Jeremy is the only son of Sarah's. Jeremy is currently married and has three children. Jeremy currently resides in Salt Lake City, Utah. This worker spoke with Jeremy on 04/30/13. Jeremy presents as well-adjusted in his life. He has not had any history of problems with law enforcement or the criminal justice system. Jeremy reports that he is currently unemployed; he states that he plays professional basketball and is preparing to go to Turkey to play basketball overseas. Jeremy states that he is more than willing to be involved in an adopted child's life. Jeremy is unable to provide substitute care for an adopted child due to the distance between them; however, Jeremy would be willing to provide substitute care in the event of an emergency if needed. He states that even though he lives a bit farther away from his mother, he visits every chance that he gets. Jeremy states that he views his mother's greatest strength as her independence. He is unable to identify any weaknesses. Jeremy states that he was disciplined by time-outs and being "talked to" while growing up. He states that his mother didn't believe in "whooping’s" and that he was never spanked as a child. Jeremy is recommending for his mother to be approved for adoption, and he does not have any concerns regarding her ability to parent a child. Jeremy does not have any mental health issues, and does not have any substance use/alcohol abuse. Jennifer M. Little, age 23. This worker spoke with Jennifer on 04/09/13. Jennifer is the youngest child of Sarah's. Jennifer is not currently married and does not have any children. Jennifer currently resides in Benton Harbor, Michigan. Jennifer presents as well-adjusted in her life. She has not had any problems with law enforcement or the criminal justice system. Jennifer states that Sarah is a great provider and that she was a "super-mom" while growing up. She reports that she and Sarah are still close with one another and that she views her mother as one of her best friends. Jennifer states that she supports Sarah 100% in her efforts to adopt. Jennifer reports that she is more than willing to provide substitute care to an adopted child if needed, and that she will continue to be involved in that child’s life. Jennifer reports that she was disciplined as a child by the removal of privileges. Jennifer does not have any ongoing reliance on Sarah for child care, monetary assistance, etc. Jennifer does not have any mental health issues, and she does not have any substance use/alcohol abuse.

Are there any rules that are in non-compliance? Yes No



Trai

ning

If Yes, list all rules and headings: Willful Substantial Supporting documentation: Variance? Yes No

9. HEALTH: (For each member of the household, both adult and children): (R.400.9201, R.400.9202, R.400.9206) Assessment of physical, mental and emotional health and substance use history.

Sarah reports that she is in good physical, mental, and emotional health. She does not have a history of substance use. She does not have any significant past or present physical problems. Dale Jacobs in poor physical health at this time. Sarah cares for Dale due to his failing health. Dale is currently diagnosed with Vascular Dementia, Congestive Heart Failure, and is also on a pacemaker and blood pressure medication. Dale is currently prescribed and taking a variety of medications for his health needs. Dale is also not in good mental/emotional health at this time, as he suffers from dementia. Dale will never care for an adopted child alone, and he also does not drive a vehicle.

Indicate current health status. (Is anyone in the household prescribed medication? If so, list the medications. How long has he/she been taking these medications/what are the medications prescribed to treat?)

Sarah reports that she is in good physical health. She is prescribed and taking Levoxly 100 mg one time per day for under-active thyroid. Sarah's thyroid condition would not prevent her from being able to care for a child appropriately. Her thyroid condition is well controlled and does not demand any additional personal care aside from taking her prescribed medication on a daily basis. Sarah is also prescribed Loratadine 10 mg, one time per day for allergies. Dale is in poor physical health. He is diagnosed with Vascular Dementia, Congestive Heart Failure and is also on a pacemaker. He is currently prescribed and taking the following medications: Plavix 75 mg, one time per day (blood thinner), Aricept 5 mg, one time per day (for dementia), Lispril 1.25 mg, two times per day (blood pressure), Vitamin B Complex, one time per day (energy level), Carpidilo 3.25 mg, one time per day (blood pressure), Armostatin 40 mg, one time per day (cholesterol), and Aspirin 82 mg, one time per day (heart disease). Dale is in failing health and has been diagnosed with dementia. It should be noted that Dale will never be alone with an adopted child and will not be responsible for caring for him or her.

Does anyone in the household have a physical or mental health diagnosis or condition that would make care of the child difficult? If so, describe how it may affect the care of a child.

Dale Jacobs is currently diagnosed with Vascular Dementia, Congestive Heart Failure and is also on a pacemaker. He is currently prescribed and taking the following medications: Plavix 75 mg, one time per day (blood thinner), Aricept 5 mg, one time per day (for dementia), Lispril 1.25 mg, two times per day (blood pressure), Vitamin B Complex, one time per day (energy level), Carpidilo 3.25 mg, one time per day (blood pressure), Armostatin 40 mg, one time per day (cholesterol), and Aspirin 82 mg, one time per day (heart disease). Dale is in failing health and has been diagnosed with dementia. He would not be able to care for a child. However, it should be noted that Dale will never be alone with an adopted child and will not be responsible for caring for him or her. There is no other person in the household that has a physical or mental health diagnoses that would make caring for a child difficult. Sarah cares for Dale due to his failing health; however, Dale's health issues do not demand an excessive amount of Sarah's time and care. Sarah reports that she ensures that Dale takes his prescribed medications and that he is able to attend his medical appointments. Dale's health does not affect Sarah's ability to care for a child placed in her home.



Trai

ning

Describe current substance use patterns, history if indicated. If there is a past substance use problem (including alcohol use) indicate how diagnosed, resolved, and when. What is the current treatment?

Sarah does not have any past substance use issues. She does not drink alcohol and does not smoke tobacco. Sarah has never received treatment for any substance use issues.

Does any member of the household smoke? Yes No If yes, do they smoke in the house? Yes No Reference a medical statement, completed within the 12 month period before conclusion of the evaluation, for each

member of the household that indicated that the member has no known condition which would affect the care of a foster/adoptive child or any other determination if different. Does anyone require special care? Please describe:

Sarah had a physical completed on 05/13/13. Sarah is in good physical and mental health. Sarah is currently prescribed Levoxly 100 mg, one time per day for under-active thyroid. She is also prescribed and taking Loratadine 10 mg, one time per day for allergies. Sarah reports that she also takes a daily multivitamin. Sarah reports that her thyroid condition would not prevent her from being able to care for an adopted child. Sarah's doctor notes that Sarah does not have a physical or mental condition that would affect the care or an adopted child. Dale had a physical completed o 3/29/13. Dale is currently diagnosed with Vascular Dementia, Congestive Heart Failure and is also on a pacemaker. He is currently prescribed and taking the following medications: Plavix 75 mg, one time per day (blood thinner), Aricept 5 mg, one time per day (for dementia), Lispril 1.25 mg, two times per day (blood pressure), Vitamin B Complex, one time per day (energy level), Carpidilo 3.25 mg, one time per day (blood pressure), Armostatin 40 mg, one time per day (cholesterol), and Aspirin 82 mg, one time per day (heart disease). Dale is in failing health and has been diagnosed with dementia. He would not be able to care for a child. However, it should be noted that Dale will never be alone with an adopted child and will not be responsible for caring for him or her. There is no other person in the household that has a physical or mental health diagnoses that would make caring for a child difficult. Sarah cares for Dale due to his failing health; however, Dale's health issues do not demand an excessive amount of Sarah's time and care. Dale has a home-health nurse that visits the home on a monthly basis to ensure that his medical needs are being taken care of. Dale's health does not affect Sarah's ability to care for a child placed in her home.


10. PARENTING: (R.400.9201, R.400.9206, R.400.9306, R.400.9401, R.400.9403, R.400.9404, R.400.9417) Parenting skills and attitudes toward children:

Sarah presents with a positive attitude toward children and parenting. She has appropriate and positive parenting skills from raising her five children.

Parenting values: Most important things for parents to do, what they will do similarly to their parents, what they hope to improve upon.

Sarah reports that she was always taught to be respectful of adults and authority figures while growing up. She reports that this is what she hopes that she will do similarly to her parents when raising an adopted child. Sarah reports that she hopes to improve upon encouraging an adopted child to achieve their goals and dreams. Sarah values education and states that two of her biological children have college degrees; she states that those two children are the only two members of her immediate/extended family that have



Trai

ning

gone to college. Sarah is very proud of this achievement, and hopes to encourage an adopted child to achieve his or her potential.

Knowledge of child development, appropriateness of expectations of children.

Sarah presents with an appropriate knowledge of child development. She presents with appropriate expectations of children.

Ability to provide infant care: Equipment, safety measures in place (e.g. gates, monitor, car seat, play area, pets)

Sarah is not interested in providing infant care. Therefore she does not have the appropriate equipment and safety measures in place. Equipment and safety measures will need to be put in place if Sarah is interested in caring for an infant in the future.

Safe Sleeping requirements have been trained and reviewed

Safe sleeping requirements were reviewed with Sarah on 03/26/13. Sarah is not interested in caring for an infant.

Understanding of infant care:

Sarah has a good understanding of infant care from raising her five biological children. Sarah is not interested in adopting a child of infant-age

Capacity and disposition to give a foster child guidance, love and affection and to deal with difficult children with

unacceptable behavior, children who are rejecting and/or oppositional, or children with medical needs.

Sarah has demonstrated her ability to give children love and guidance through discipline. Sarah states that she would demonstrate love with a child that displayed very difficult behaviors. She reports that she is willing to participate in therapy services and is comfortable seeking community resources and assistance if needed. Sarah presents with a positive attitude, and with the ability to accept an adoptive child into her home. She has shown her ability to be supportive and nurturing through discipline.

1. What kinds of behaviors require intervention?

Sarah reports that behaviors that require intervention include lying, stealing, truancy/school problems, being overly defiant, and violent or self-harming behaviors. She is comfortable seeking professional resources to aid her in dealing with these types of behaviors. Sarah reports that she utilizes time-out and the removal of privileges as discipline techniques. Sarah also has the ability to access community resources if needed. She is aware of post-adoption resources in Berrien County should she need to utilize them in the future. She understands the Child Management Policy and understands that physical punishment of any kind is prohibited. Sarah signed the Child Management Policy on 03/26/13, and a signed copy is located in her family file.

2. How will caregiver intervene/handle that type of behavior? How will they be supportive and nurture children?

Sarah reports that she utilizes the taking away of privileges and time-outs as discipline techniques. She understands the Child Management Policy and understands that physical punishment of any kind is prohibited. Sarah understands that when presented with behaviors that she is not comfortable handling that she can seek the assistance of professionals. Sarah reports that she is open to therapy services for an adopted child if needed. She understands that adopted children may benefit from participating in therapy, and she is open to counseling.

Methods of discipline. Flexibility and age appropriateness of approaches, willingness to follow the case plan for the child if it differs from their normal approach to discipline.

Sarah reports that she uses the taking away of privileges, time-outs, positive reinforcement, groundings, lectures, and talking with the child as methods of discipline. Sarah is willing to follow an individual child's care plan if the child has specific behavioral needs. Sarah understands that physical punishment is inappropriate and



Trai

ning

prohibited for any and all children placed in her home.

Awareness of variety of techniques, use of positive and negative methods.

Sarah is aware of a variety of discipline techniques. She is willing to tailor these techniques to an individual child's needs. Examples of positive discipline include verbal praise, and positive reinforcement to positive behaviors. Negative discipline techniques that Sarah will not use with a child placed in her home are spanking, physical restraint, shaming or put downs.

Understanding of agency’s discipline policy and willingness to abide by it. If the family has used spanking or other

corporal punishment, or was raised with it, document their current attitudes.

Sarah reports that she is willing to abide by the agency’s policy on physical discipline. She is also willing to follow each child's individual behavior plan if it is different from her normal approach to discipline. Sarah read and signed the Child Behavior Management Policy on 03/26/13. A copy is located in her family file.


11. MOTIVATION FOR FOSTER CARE/ADOPTION: (R.400.9201, R.400.9202, R.400.9206, R.400.9403, R.400.9404, R.400.9405, R.400.9411)

Reasons for wanting to provide care for relative/foster/adoptive children, including infertility, if indicated.

Sarah feels that she has good parenting skills and a lot of love to provide to a foster child. Adoption is something she has always wanted to do and she feels that she is finally at a point in her life where she can open her home to an adopted child.

Each member’s attitude towards accepting a relative/foster/adoptive child.

Sarah is very open and accepting towards the idea of adopting a child. Her father seems open and supportive, however he will not be engaged in any of the day to day parenting of a child in the home.

Previous experience in providing child foster care, child day care, or adult foster care.

Sarah does not have any previous experience in providing child foster care, child day care, or adult foster care.

Previous adoptive evaluations or placements. Sarah does not have any previous adoptive evaluations or placements. Previous licenses, including applications that did not result in a license. Reference communication with previous agency.

Sarah does not have any previous licenses, including applications that did not result in a license.

Level of understanding of foster/adoptive care and the potential impact of their family. For example, does the caregiver understand that a social worker will visit the child and relative at least monthly until reunification with parents occurs or permanent custody is achieved?

Sarah is aware of the involvement of the agency throughout the adoption process and she is open to being cooperative. She expects there to be an adjustment period for any child placed in the home and hopes that overall adoption has a postive impact on her family.

Evaluation of motivators, (if adoption/relative placement in particular).

This worker has evaluated Sarah's motivations for adoption during several telephone calls and home visits over the past few months. Sarah's motivations are appropriate for wanting to adopt a child.

Applicant(s) agree to encourage visits and follow health care, religious and discipline policies of this agency



Trai

ning

Sarah agrees to encourage visits, and to follow health care, religious and discipline policies of the agency. Sarah agrees to encourage sibling visits, as well as visits with other significant persons. Sarah signed the agency’s Child Injury and Illness Policy and the Child Management Policy on 03/26/13. She understands that physical discipline is not to be used as a consequence in the home. She also signed the Weapons Notification Policy and was given the Adopting a Child in Michigan Policy on 03/26/13. All copies are located in her family file. Sarah agrees to encourage visits between an adopted child and any significant persons in the child's life. She has demonstrated her ability to maintain communication and contact with significant persons, and is able to schedule visits on a regular and consistent basis.


12. FAMILY’S ATTITUDES TOWARD THE CHILDREN’S PARENTS AND WORKING WITH THE AGENCY: (R.400.9201, R.400.9202, R.400.9206, R.400.9403)

Understanding of permanency and concurrent planning.

Sarah understands that adoption is permanent and she is committed to providing permanency for an adoptive child. She understands that the child's birth parental rights have been terminated and that the child is legally free for adoption. She wants to provide a child with a stable and permanent home environment.

Family’s level of understanding of foster/adoption care.

Sarah presents with an appropriate understanding of foster care and adoption. She understands that adoption is permanent and wishes to provide permanency to a child through adoption. Sarah attended PRIDE sessions 1,2,3,4, and 6. Sarah is willing to assist an adopted child in gaining understanding of his or her history, religious preference, and their racial and cultural identity. She understands the importance of maintaining significant relationships in an adopted child's life. These relationships can include siblings, biological relatives, and former caregivers. Sarah has demonstrated her ability to maintain contact and communication with significant persons in a child's life, and has shown that she is encouraging and supportive for a child to have on-going contact.

Family’s willingness to comply with the child’s case plan. If child is in the home, assess current situation.

• The family is willing to cooperate with the supervising agency. • The family is willing to cooperate with the school system. • The family is willing to cooperate with the child’s therapist. • The family is willing to cooperate with the parenting time plan outlined in the treatment plan. • The caregiver is willing and able to protect the child(ren) from further harm.

Sarah is willing to comply and cooperate with any case planning for an adopted child. Sarah is also open to learning further information or attending any relevant training if needed. Sarah is willing and has been very cooperative with this worker and the agency throughout the process. She is willing to cooperate with the school system, and she is also willing to cooperate with a therapist should an adopted child need therapeutic services in the future. Sarah is also willing to protect an adopted child from any further harm. She states that she is open to future contact with an adopted child's birth mother if deemed appropriate in the future.

Attitudes toward the legal parents. How will foster parents discuss legal parents with and around foster/adoptive children?

Sarah reports that she will be open and honest in discussing a child's birth parents with an adopted child. She reports that she will not speak negatively about birth parents.



Trai

ning

Sarah states that she will encourage adopted children to be open about their feelings and thoughts regarding their past experiences, as well as subsequent adoption. She states that she wants to support an adopted child and will encourage them to speak openly in the home about their feelings.

How will foster parents discuss reasons children entered foster care and/or became available for adoption?

Sarah reports that she will discuss the child's history with them at an age-appropriate level. She reports that she will keep adoption an open topic in the home and will encourage an adopted child to ask her any questions. She reports that she will not speak negatively about the child's past history and/or birth parents.

Family understands the goal of the agency in providing foster care and they are willing to support the agency in working toward reuniting a foster child with his or her family.

Sarah is not interested in fostering a child. Sarah is only interested in children who are permanent court wards and that are available for adoption.

For Relative Placements:

• Does the family agree to not release the child to anyone, including birth parents, without the supervising agency’s approval? Yes No

• Does the family agree they will not allow the foster child(ren)’s parents to live in their home without the supervising agency’s approval? Yes No

• Does the family understand they cannot be licensed to care for foster children whose parents live in the home? Yes No

Ability to empathize and work with the parents and children.

Sarah presents with an ability to empathize with birth parents and children. Though Sarah is only interested in adoption, she recognizes that situations may arise in the future with birth parents. Sarah is open to working with birth parents in the future if deemed appropriate.

Openness to maintaining significant relationships.

Sarah is open to maintaining the significant relationships present in a child's life. Sarah presents with an understanding of the importance of maintaining these important connections, and she is willing and able to maintain contact and communication with persons who are significant.

Openness to providing permanency to the relative/foster child if needed.

Sarah is only interested in providing care to a child that is a permanent court ward and available for adoption. Sarah is not interested in fostering.

Ability to comply with agency policies and procedures.

Sarah has demonstrated her ability to comply with agency policies and procedures. She has completed an initial orientation, two home visits, and has read, reviewed, and signed agency policies and procedures. Sarah also has completed PRIDE training sessions 1-4 & 6.

Summarize experience of caseworkers for children who have been placed in the home. Assess current compliance.

Sarah does not currently have a child placed in her home and has not had any other placements at this time. She has been very open and compliant in working with this worker on her adoption.




Trai

ning

13. TRAINING NEEDS: A statement of the number of hours the person/couple need to comply with the training rules is not sufficient. (R.400.9415)

Orientation and training hours credited; include topics covered.

Sarah completed an initial orientation with this worker on 03/26/13. She attended PRIDE training sessions 1-4 and 6 on 05/09/13 and 05/10/13 at Berrien County DHS. The following topics are covered in PRIDE: Session 1 & 2: Connecting with PRIDE and Teamwork toward Permanence Session 3: Meeting Developmental Needs: Attachment Session 4: Meeting Developmental Needs: Loss Session 6: Meeting Developmental Needs: Discipline Copies of Sarah's attendance on these dates are located in her family file.

Types of training the family believes they could benefit from.

There are no specific types of training that Sarah believes that she could benefit from at this time. She presents open and willing to attend any future trainings if needed.

Worker’s assessment of additional training needs and the agency’s plan to provide the identified training.

Sarah would benefit from receiving training that is child-specific. She would benefit from training that covers topics related to the child that is placed in her home, and the needs that this child may demonstrate. This worker will continue to assist Sarah in identifying any additional training that may benefit her one she is matched to a child.

Openness to learning.

Sarah presents with openness to learning. She is not afraid to ask questions, and presents comfortable asking others for help. Sarah is open to attending trainings in the future if needed.


14. TYPE OF CHILDREN DESIRED – INTEREST IN PERMANENCY/ADOPTION PLANNING: (R.400.9201, R.400.9202) Gender, race, ethnic background and special characteristics of children preferred by applicants. Types of children the family is willing to consider.

Sarah prefers to adopt a female of any race between the ages of 6-16. She is willing to consider a male child as well depending on the needs of that child. Sarah is open to a child with up to moderate emotional, educational and physical impairments. She does not feel that she can meet the needs of a medically fragile child. She is willing to parent a child who has up to moderate behavioral issues.

Ability and willingness to care for special needs children, and the problems of the children.

Sarah is willing and able to care for a special needs child. She is aware of the common behavior problems that children in the foster care system have and is prepared to meet those children's needs. Sarah does not feel that she is able to parent a child with severe medical impairments or severe emotional or behavioral issues.

Interest in adoption. This assessment is only being completed for the purposes of adoption.

If this evaluation is being completed for an adoption of a specific child, the DHS 612, Adoptive Family Assessment Addendum, must be completed.

When a child is identified for Sarah, a DHS 612 will be completed. Department of Human Services Office of Workforce Development and Training


Trai

ning

15. CROSS CULTURAL PLACEMENT: Willingness to parent cross-racially or cross culturally and to create an atmosphere that fosters racial identity and culture

of a foster child.

Sarah is open to parent cross-racially and/or cross-culturally. Sarah is open to exposing a child to their ethnic heritage. She is also willing and able to create an atmosphere that fosters racial identity and culture of an adopted child. Sarah reports that she is willing and able to accommodate a child's specific religious needs of a child placed in her home. Sarah is willing to assist an adopted child in gaining an understanding of their individual history, religious preference, racial preference, and cultural identity.

Races or cultures requested or that the family does not believe they can effectively parent.

There are no races and/or cultures requested or rejected. There are no races and/or cultures that Sarah believes she cannot effectively parent.

16. REFERENCES: (R.400.9206) At least three references must be obtained from persons not related to the applicant(s).

This worker received a personal reference from Lori Abrams on 04/01/13. Lori states that she has been friends with Sarah for over 25 years. This worker received a personal reference from Ken Stiles on 04/01/13. Ken reports that he has known Sarah for 3 years. He states that he is Sarah's boss. This worker received a personal reference from Megan Holland on 04/18/13. Megan states that she has known Sarah for her entire life, and that her mother was friends with Sarah's mother growing up.

Summarize the information received from each reference. If negative information was received, explain how the negative information was resolved.

One reference states that Sarah is a great person with a big heart. This reference states that Sarah was a good mother to her five kids, and that she did a great job. She states that her kids love her and that she is patient with her children. This reference notes that Sarah is a people-person, and that she always gets along with the community and public. She states that she does not have any concerns regarding Sarah's ability to parent a child, and she is recommending for Sarah to be approved for adoption. Another reference states that Sarah is an honest person who is respected by others. He states that he has met some of Sarah's children and that she has done an excellent job raising her children. He states that all of her children are doing well because of Sarah's ability to parent them. This reference states that Sarah is well-respected by others and that she gets along well with others. This reference does not note any concerns regarding Sarah's ability to parent, and is recommending for Sarah to be approved for adoption. The third reference states that Sarah is a caring and intelligent individual. This reference states that Sarah is a great parent and that she often goes to Sarah for advice with her own children. This reference states that Sarah gets along with others very well and that she is always willing to help others. This reference recommends for Sarah to be approved for adoption. She does not have any concerns regarding Sarah's ability to parent a child.

An agency may choose to obtain additional references from related or unrelated persons, including adult children.

Sarah has five adult children. This worker received an Adult Child Reference from Janessa Franklin on 04/09/13. This worker received an Adult Child Reference from Jennifer Little on 04/09/13. This worker received an Adult Child Reference from Jackie Gaines on 04/10/13. This worker received an Adult Child Reference from Jeremy Franklin on 04/30/13. This worker received an Adult Child Reference from Jenna Franklin on 05/08/13.



Trai

ning

One reference states that Sarah is a great mother and that she has great character. She states that her mother is very hard-working and that she has always provided for her family. This reference states that she was disciplined by the removal of privileges and being sent to her room while growing up. She describes her current relationship with Sarah has been very close. She states that they talk to each other at least once per day, and socialize with one another on the weekends. This reference is very supportive in Sarah's efforts to adopt. This reference is recommending for Sarah to be approved for adoption. Another reference states that Sarah's greatest strengths are being a provider. She states that Sarah was a "super-mom". This reference states that she was disciplined by the removal of privileges growing up. She states that she and her mother are very close today, and that she considers her mother to be one of her best friends. This reference states that she supports her mother 100% in her efforts to adopt. She is recommending for Sarah to be approved for adoption. Another reference states that she views her mother's greatest strengths as being a nurturer and provider. She states that she views her mother's greatest weakness as that she is a working parent. This reference states that she was disciplined by the removal of privileges growing up. She states that she and her mother are very close today, and that they talk on the phone on a daily basis. This reference states that she often turns to her mother for wisdom and advice. This reference is very supportive in her mother's efforts to adopt. This reference states that her family is very close to one another and that her family wants to take care of one another. This reference is recommending for Sarah to be approved for adoption. The fourth reference states that he views his mother's greatest strength as being her independence. He was unable to identify any weaknesses. This reference states that his mother did not believe in physical discipline while growing up; he states that he was disciplined by the removal of privileges or that his mother would talk with him about the negative choices that he had made. This reference states that he talks with his mother on a regular basis, and that they try and visit with one another as much as possible. This reference is very supportive in his mother's efforts to adopt. This reference is recommending for Sarah to be approved for adoption.

If this is an adoption assessment and there are circumstances that require additional review, include the information provided by the professional reference.

There are no circumstances that require additional review. There are no professional references.

17. RECOMMENDATIONS: (Must be consistent with the information contained in the report.) Placement with relative is recommended: Yes No N/A If the recommendation is that placement should not be made, the reason for this must be explained in detail. Licensure/Adoption is recommended: Yes N/A • Summary of strengths and areas of growth, attention.

This assessment is being completed for adoption purposes only. Sarah is recommended to be approved for adoption, but was not assessed for foster care licensure. Sarah is a friendly, mild-mannered, open and nurturing individual. Sarah has



Trai

ning

demonstrated strong parenting skills with her birth children and is excited and open to the idea of parenting an adopted child. Sarah is also open to learning and is willing and able to attend any training in the future if needed.

• Issues to be considered in making placements

Sarah works full-time outside of the home. The only issue that should be considered when making a placement is that the child should be of school-age. Sarah's home is not wheelchair accessible, therefore a child that is physically challenged would not be able to be placed in Sarah's home.

• Recommended placement specifications to include characteristics, age, sex, and number of children best served by

home and types of children who may not be placed in the home.

It is recommended for Sarah Wright to be approved for the adoption of one female child of any race between the ages of 6-16. Sarah would like to adopt a child with mild to moderate physical, cognitive, educational, and developmental needs. It is recommended for any children placed in her home to be of school-age, as Sarah works full-time outside of her home.

Recommendation for License Denial: • List all rules found to be in non-compliance. • Summarize facts to support rule non-compliance. • Reference all supporting documentation.

Recommendation for Adoption Denial: • Basis for recommendation: • Supporting documentation. 18. CLOSING: Relative Assessment Submitted by:

Name:

Signature: Agency:

Title:

Date:

Licensing/Adoption Assessment Submitted by:

Name: Kelly Travis

Signature: Department of Human Services Office of Workforce Development and Training


Trai

ning

Agency: Adoptions for Michigan Children

Title: Adoption Social Worker

Date: 06/14/13

19. SUPERVISOR’S REVIEW: Application: 03/27/13 Clearances: Sarah - 3/27/13, 4/4/13, 5/10/13

Dale - 3/27/13, 4/22/13, 5/10/13 Medical Reports: Sarah - 5/13/13, Dale - 3/29/13 References: Lori Abrams - 4/1/13; Ken Stiles - 4/1/13; Megan Holland - 4/18/13 Other documentation: Orientation - 3/12/13; Weapons and Discipline Agreements 3/26/13 Is the report accurate, factually consistent, unbiased, support by adequate data/information? Yes No Further Explanation: Report is approved by supervisor

Supervisor Name: Eric Matthews

Signature: Agency: Adoptions for Michigan Children

Title: Adoption Supervisor

Date: 6/28/13 Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.



Trai

ning

bcal-3130-a, initial evaluation€¦ · sarah reese - r 345 963 983 009, expires 5/24/15, on file...

Documents