File No by 3HHbA5Gi


									                                    Pathway of Hope
                               Youth and Family Services
                             Placing Worker File Check List

Resident: _____________________________________________________
Date of Initial Court Wardship: _________________________________
Date of Placement: ____________________________________________
Date of Birth: _________________________________________________

           Please check off and fax or mail the following prior to placement:
  o   Court Order
  o   Bed Exception Certificate
  o   Copy of Birth Certificate
  o   Copy of Social Security Card
  o   Face Sheet
  o   Application for Admission
  o   VCR Consent Form
  o   Consent for Detention
  o   Consent for Placement
  o   DSS-3600
  o   Initial Service Plan from Probation Officer of DHS Worker
  o   School Credit History and/or Recent School Information
  o   Immunization Record
  o   Medical/Dental Contract signed/dated
  o   Medicaid/Insurance Card
  o   Medical Passport and/or Recent Physical and Dental Record
  o   Psychological/Psychiatric Reports
  o   Medication Information
  o   Recent Report by Placing Worker/Agency

Worker Signature                                        Date:

                                         Pathway of Hope
                                           PO Box 1128
                                       Evart, Michigan 49631
                                            Face Sheet
                                                                              Admission Date
                                                                              School Status
                                                                              Legal Status
I.     WARD

Name of Ward                                       D.O.B.        Sex          Age Grade
Home Address                                       City          State        Zip Code
Place of Birth                              Soc. Sec. #                Religious Preference
School Last Attended                               Address
MA#:                                 Insurance:
Color of Eyes                 Hair          Weight        Height              Race
Identifying features
Special Medical Needs (allergies, etc.)

II.    Referring Agency

Agency’s Name                        Address
Worker’s Name                               Title
Phone #:                             Committing County
Fax #: _____________________________

II.     Family Information
Child Lives with: Natural Father   Natural Mother           Adoptive Parents     Step-Mother
                  Step-Father      Foster Parents           Guardian

Father’s Name:                      Step-Mother/LTP:
Phone #: (H)                   (W)                                   (Mess)
SS # ______________________________

Mother’s Name:                      Step-Father/LTP:
Phone #: (H)                  (W)                                   (Mess)
SS # ______________________________

Marital Status of Both Parents:
Do Both Parents Have Parental Rights Yes No If no, explain:

Concerned Relatives                        Phone:                   Relationship:
Name:                                      Phone:                   Relationship:
Phone/Visitation Instructions:

SIBLINGS (continue on reverse side if necessary)       FULL      HALF    STEP       ADOPTED

       NAME                                        AGE                              WHEREABOUTS

                                    Application for Acceptance to
                                          Pathway of Hope

This information is confidential. The information in this application will not be held against you or used to judge you
in any way. Pathway of Hope is dedicated to helping young ladies heal and restore their lives. Please answer all
questions honestly so we may know how best to help you.

Name:                                                                      Name you go by

Present Address:

Telephone #:                                  Parent/Guardian


Telephone #:                               Referred by: FIA                Court        Parents          Other

Information About You

Date of Birth:                     Age:                        Race:
                                                                       If Native American, what tribe?
City and State of Birthplace:

Social Security Number:                   -        -

Driver’s License Number (if applicable)

Physical Characteristics:

Height:           Weight:          Eye Color:                  Hair Color

Religion Preference:

Hobbies and Interests:

Other Pertinent Information:


Are your immunizations up to date? Yes                         No

Do you have any allergies? Yes                    No                   I

If yes, list:

List any medications you take:

       Medication              Dosage                  Reason                      For How Long

Are you on a special diet? Yes           No                If yes explain:

Was this diet prescribed by a Doctor?           Doctor’s name and phone #:

Do you presently have, or have you ever had an eating disorder?              Explain:

Have you been diagnosed with an eating disorder, or treated by a physician?

Doctor’s name and phone #:

List any physical limitations that you may have


List all past surgeries, or hospitalizations (include dates):

Have you been sexually active at any time:

To the best of your knowledge are you pregnant at this time?

If yes, are you under the care of a physician ________ Physician’s name and phone #:

Family History

Brothers and Sisters – List including stepbrothers and stepsisters.

                                             1                        2

Full Name



Living at Home

Court Involvement

Police Involvement

Marital Status

City/State Res.

                                             3                        4

Full Name



Living at Home

Court Involvement

Police Involvement

Marital Status

City/State Res.

Parent Information:

                           Father       Mother   Step Parent
Full Name
City, State, Zip
Home Phone
Work Phone
Date of Birth/Age
Place of Birth
Religious Preference
Marital Status
Marriage Date(s)
Divorce Date(s)
County of Divorce
Custody Granted to
Visitation Rights
Educational Level
 City, State, Zip
 What hours
Family Yearly Income
Social Security No.
Veteran Status
If Deceased, Date, Cause
With Whom
Health Insurance
  Policy No.
  No. Dependents


Have you ever been to counseling?              (Please list facilities below)

Have you ever received psychiatric care or been in a psychiatric hospital?             (please list …)

Have you ever been diagnosed, or treated for MPD/Dissociative Disorder                 ADD

ADHD            Schizophrenia          Bi-Polar Disorder               Borderline Personality Disorder

Have you ever experimented with the following substances? (Circle)
      Alcohol                      Hallucinogenic (Acid, LSD…)          Morphine
      Amphetamines (uppers)        Crank                                Opium
      Barbiturates                 Crystal Meth                         Heroin
      Cocaine                      Marijuana                            Tobacco
      Crack                        Meth Amphetamines
      Other:                       Inhalants (Glue, Paint Thinner, etc…)

Drug of Choice

1)                     Length of Use
2)                     Length of Use
3)                     Length of Use
4)                     Length of Use

Why do you depend on drugs? (Circle)
      To cope with life
      For pleasure
      To escape reality
      To be in with the crowd

Habit cost per day?                            Longest period clean?

Date of Entry         Program Name           City/State               Reason for Discharge & Date

Have you ever been a victim of rape            or incest              ? How old were you?

Have you ever been the victim of sexual abuse          Physical abuse           or ritual abuse          ?

Have you ever been involved in prostitution?

Have you ever tried to commit suicide?         If yes when?


Have you ever self-mutilated?

                                              Consent for Placement

This form is a signed agreement for the placement of _____________________ and between Probation Worker,
StateWorker, or Private Placement Families. As to the the referring agency to release the resident for placement
into the Pathway of Hope program. This consent will permit us to proceed on with setting up the residents need for
treatment. This form is a temporary until a court order is established from the referring agency and county.

Probation Worker:___________________________

State Worker:_______________________________

Private Placement:___________________________



Pathway of Hope Worker:______________________

                                       Pathway of Hope
                                       Youth & Family Services

   Permission For Use of Photographs, Slides And/Or videos for Fundraising And
                            Public Relations Activities


Pathway of Hope is a nonprofit organization which, from time to time, engages in public
relations programs. In connection with these programs it is helpful to Pathway of Hope to be
able to use photographs, slides or video recordings of our staff and clients.

The purpose of this Permission and Release Form is for you to give written permission to
Pathway of Hope to take pictures or video record our clients and to use the same in fundraising
public relations activities. If you will grant such permission to Pathway of Hope, please sign in
the space provided.

Permission to make and use photographs and/or recordings

I,                            give permission to Pathway of Hope to make photographs, slides,
and video recordings of me and to use them in connection with Pathway of Hope fundraising
and public relations activities.

I also consent to the use of my name in connection with Pathway of Hope’s public relations

Signature of Subject                             Date

If subject is a minor, signature                 Date
of parent or guardian

If subject is a state or court ward,             Date
signature of caseworker

                                      Pathway of Hope
                                     Youth & Family Services

                                     Admission Status Form


Date of Birth:                                   Today’s Date:

A.      Preparation for placement;

B.      General physical and emotional state at the time admission:

C.      Circumstances leading to the need for care.

                                         Billing Information

Resident’s Name: _________________________________________________________

County that resident if from: ________________________________________________

Permanent or temporary ward of the state? _____________________________________

Worker’s Name: __________________________________________________________

Who is responsible for paying the billing? _____________________________________
    DHS
    Court
    Title 4E
    Private
    Other

Address of Payer: ____________________________________


Telephone #: ________________________________________

Contact Person: ______________________________________

Have all authorizations for payment been cleared? ______Yes _______No

Has the form 626 been completed and approved? ______Yes _______No

                                           MEDICAL/DENTAL CONTRACT

                                                      Child’s Name

I/we the undersigned, give our consent to the authorities of Pathway of Hope to act in loco parentis when, upon the advice of a
physician, surgeon or dentist, immediate surgical or dental care is required by my/our child and to be immunized as needed
according to the recommendation of the Michigan Department of Public Health.

I/we transfer and assign to any hospital or clinic in which my/our child is confined or treated, all hospitalization and insurance
proceeds that may be due me. I /we further agree and promise to pay any amount not covered by insurance.

Please state whether your child is covered by Medicaid. (Pathway of Hope requires all children who are eligible to be covered
by Medicaid).

Yes _______          Medicaid Number ___________________________________
No _______           If no, has application been made by referring agency? __yes ___no

Please state whether your child is covered by any medical, dental, or hospitalization insurance.      _______yes       _______no

If yes, please give the following:

Name of Employer ______________________________________________
Name of Insurance _______________________________________________
Policy Holder     _______________________________________________
Policy Number     ________________________________________________
Policy Holder’s SS# _______________________________________________

____________________                                            ________________________
Witness                                                         Parent or Legal Guardian

____________________                                            ________________________
Date                                                                   Date

                                        INTAKE MEDICATION INFORMATION

1. Is the resident currently on any medication? Yes No

If so, please list the medication and dosage below:

_____________________________                 ________________________________

_____________________________                 ________________________________

_____________________________                _________________________________

2. What is the name and contact information of the physician or psychiatrist that most recently prescribed the medication?


3. What is the date of the last medication review?


4. Is there a medication review currently scheduled?


* Please include any psychological evaluations and/or any important medical information with the intake information.

                                             Important Case Information

1.    What is the name and address of the resident’s attorney?

2.    Will the resident be eligible for a clothing order while in placement at Pathway?

Yes    No

If Yes, please answer the following questions:

Date of Last Clothing Order: ________________________________

Date of Next Clothing Order: ________________________________

Amount of Next Clothing Order: _____________________________

3.    Please list the names, phone numbers, and addresses of people that the resident is allowed to have contact with:





4. Do you give permission for the Case Manager, Supervisor, and Director to screen
all incoming and outgoing mail? Yes No

5.    What is the date of the next scheduled Court Hearing? ____________________

6.    Are there any Court Fees/Fines due? Yes No

      If Yes, what is the amount? __________________________________

                           Temporary Consent for Detention

This form is a signed agreement for a temporary stay at the Muskegon River Detention
Facility in Evart MI. Due to times when a emergency situation will arise for a warranted
detention stay, it is important that we have a release from your county to place the current
resident __________________ if need be. This temporary placement will occur only when
this agency cannot make contact with the worker. Pathway of Hope will at all times seek
other alternatives before using the Muskegon River Detention Facility. Such as de-
escalation, phone call to the worker, and counseling. Again this form is for the consent of a
temporary stay at the Muskegon River Detention Facility.

PROBATION OFFICEER: _______________________________________

STATE WORKER; _____________________________________________

PRIVATE PLACEMENT; _______________________________________

PARENTS; ___________________________________________________

DATE; _______________________

COUNTY; ________________________________________

PATHWAY OF HOPE WORKER; ________________________________


Resident Name: ________________________________________________

DOB: _______________________

Placing Agency: _____________________________________

Worker: _________________________________________________

The following behavior may be grounds for immediate discharge from the Pathway of Hope program;

       Self-Harming Behaviors, Threats of Suicide
       Physical Assaults on Staff or Residents
       Destruction of Property
       Runaway

The following plan will be used in an emergency:

        1) Call to Worker or Agency at the following number (must be

         someone accessible 24 hours a day/7days a week) _______________.

        2) Call to ______________________ at _____________________
                   (name of facility)                 (phone number)

        Which is the preferred secure facility.

Please provide a summary of any other instructions that Pathway of Hope should follow to ensure safe and immediate removal:


_____________________________                         _____________________________
Signature of Placing Agency Worker                    Parent/Guardian (When applicable)

_________________________________                    __________________________________________
Scott Gardner, MA Director                           Angela Montgomery, BA Case Manager/Supervisor

                                         Pathway of Hope Intake Packet
                                              School Information

Resident Name;
Date of Admission:

Section 53 Documentation (Required by State Law)

I hereby certify that I am the parent/legal guardian of _________________________born

___________________. My address, including street, city and state is:

_____________________________________________________________. The student

is a resident of the following school district: _________________________________.

      A. Please list all public and private schools, detentions, community education and/or private settings
           where high school credits may have been earned. If in Junior High School list the last school attended.
Name of School   Highest Grade         Dates Attended      Special           Special Ed.
                 Completed                                 Education         Eligibility (EI,
                                                                             LD, OHI)
                                                           __Yes __No
                                                           __Yes __No
                                                           __Yes __No

        B. Please check if there are any school related problems in the following areas:

        ____Math                         ____Attention Deficit            ___Truancy

        ____Lack of Coordination         ____Physical/Verbal Aggression

        ____Reading                      ____Writing                      ____Authority Issues

        ____Lack of Retention ____Disruptive Behaviors            ____Comprehension

        ____Work not Completed           ____Other (Please Describe): _________________

        C. Please check all areas in education that are successful for this student:

        ____Academic Classes             ____Extra Curricular (Sports)

        ____Vocational Experiences               ____Art, Music, Drama, etc.

I understand that clients in Pathway of Hope’s care receive education services through the school
district in which they reside and that additional services (i.e.; special education classes, resource
room tutors, teacher consultants, and vocational classes), if needed, are determined at Individual
Educational Planning Team (IEPT) Meetings. I understand that I will always be invited and
encouraged to attend these meetings. I realize that the Educational Coordinator, Program
Administrator, therapist/foster care worker, and foster parent (if applicable) will also attend to
represent Pathway of Hope, advocate for my child and assist in the process of providing the best
educational services for my child. State guidelines require that residents, who are currently Wards
of the State with no relatives as acting guardian or where a parent/legal guardian cannot be
located, will have a surrogate appointed by the school to represent the best interests of the client
during the IEP process.

I hereby consent to have Pathway of Hope personnel be present at any IEPT and authorize him/her
to sign all school related permission forms (e.g., enrollment, field trips, release of record,
immunizations) in my absence and on my behalf to ensure continued educational services for my
child or Ward. I am aware that this authorization may be withdrawn at any time and that it will be
the responsibility of Pathway of Hope to keep me informed of the academic progress of my

I certify the above to be true and hereby authorize Pathway of Hope Youth and Family Services to
release required information regarding my child or Ward for the purpose of school planning,
including that which is needed, for post-discharge educational planning. I also agree that the
school district my child is attending may release my child’s education records to Pathway of

Parent/Guardian (Where Applicable)                                  Date

Angela Montgomery, BA                                                Date
Pathway of Hope Case Manager/Supervisor

Scott Gardner, MA                                                   Date
Pathway of Hope Director

                                         Pathway of Hope Security System

A.       Our security system is a Brooks Security DVR system installed by Brooks Security & Electronics out of Baldwin,
        16 Camersa
        Stores information up to 2 weeks and then it erases the hard drive.
        24/7 surveillance for staff only
        The security alarms are monitored by Brooks Security and Police 24/7
        Monitor is located in the basement
        Security key pad is located to left of main entry door.

B.       Security Keypad:
          Used to tell the staff the status of the house (which windows or doors are open)
          Used to set the alarm at night
          Used to quick dial police, ambulance, & fire

C.       Cameras
          May be adjusted by supervisor on duty with a witness.
          Does have blind spots (all staff must be aware of blind spots at all times) Staff are not to assume the cameras
            are their eyes. It si a safety tool.
          Can view specific time and camera, by accessing the main computer.
          There is NO audio


     Staff must have at least 1 hour of training.
     Will do a walk around of the house and be informed of where all cameras are.
     Will be instructed on the use and operation of the complete system and all its functions.
     There will be a refresher training done for the complete system every 6 months. This will also be documented and
       signed by supervisor.

Contact Numbers:
        Brooks Security 231-745-7549
        State Police    231-832-2221

Angela Montgomery, BA

Scott Gardner, MA

                              Pathway of Hope Security Camera Policy Form

I have read the Pathway of Hope camera policy and understand there are camera’s in the Pathway of Hope home for security
reasons. I understand that it is also for protection of the residents and staff in the event of a physical restraint. I know that there
is no audio to this system. I am in agreement of this policy.

Resident                                                           Date

DHS Worker/Probation Officer                                       Date

Parent or Guardian (when necessary)

                                      Parenting Guidelines for Staff and Resident Moms
The following is a set of guidelines and expectations for our resident moms and for staff. The goal is for the staff to be able to
assist the moms as well as hold them accountable in their daily parenting. Keeping each mom and baby healthy and safe is our
    1. Diaper Changes
            Moms need to note a diaper change every 3 hours of awake time in their log book. In addition,
               the moms need to change the diaper within 30 minutes of the child waking up from a nap/sleep
            If the mom has not changed and logged the diaper changes, the staff will approach the mom and
               ask for this to be completed. If the mom refuses, the staff will change the diaper.
    2. Feeding
            The mom is responsible to log feeding times and include a description of each snack/meal that
               corresponds with the outlined needs for the age of the child found in the Parenting Binder.
            If the mom has not logged and fed the child as outlined, the staff will approach the mom and ask
               for this to be completed. If the mom refuses, the staff will feed the child.
    3. Bathing
            The mom is responsible to log that the child has been bathed one time in every 48 hours. The
               mom is expected to inform the staff on duty when she is going to bath the child. The staff may
               check the temperature of the bath water.
            If the mom has not bathed the child in 48 hours, the staff will approach the mom and ask for this
               to be completed. If the mom refuses, the staff will bath the child.
    4. School and Daycare
            The mom is expected to attend school daily unless ill or excused for an appointment. The child
               will attend daycare during school hours.
            The staff may transport the child to daycare if necessary.
    5. Night Hours/ Lights Out
            The mom is expected to get a minimum of 5 hours of sleep on school nights.
            The upnight staff will care for the child if the child is awake more than 5 hours during the night.
               The mom is also expected to follow the guidelines regarding night hours outlined in the Parenting
    6. Safety During Crisis
            If the mom becomes verbally and/or physically aggressive at any time, the child will be removed
               from the situation. The child will be returned to the mother’s care once the mom has de-
            If another resident becomes verbally and/or physically aggressive at any time, the mom will be
               asked to remove the child from the situation immediately.
    7. Attending to Needs
            If a child has cried for over ten minutes and the mom has not attempted to meet the needs of the
               child than the staff on duty will attempt to meet the needs of the child.
    8. Log Books
            Completing the daily Log Book is the responsibility of the mother.
            The staff on duty will check the Log Book at the end of each shift.
            The Parenting Educator and/or Case Manager will check the Log Book once weekly. If the Log
               Book has not been consistently filled out and/or the needs of the child have not been consistently
               met the following actions may be taken: 1) the placing worker will be notified, and/or 2) the
               mother will be dropped to Level One.
    9. Each mother will be assigned a “helper” from her peer group. The helper is the only other resident
       allowed to have contact with the child. The helper is not to be the primary caregiver. The role of the
       helper is to “fill in” for brief periods of time when the mom is completing another program requirement.

The staff on duty are expected to share any concerns with the moms in private on the same day noted. The staff
will report any abuse or neglect immediately to the Case Manager, Supervisor, and/or on-call supervisor.

The staff are encouraged to note and express the positive parenting skills demonstrated by each mom.

Resident                                                      Date

Case Manager                                                  Date

Placing Worker                                                Date


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