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PERMANE NCY HEARING REP ORT PERMANE NCY HE ARING DAT E CE RTAI N: / / Judge / Referee Court Part IN THE MATTER OF : Child’s Name Date of Birth Sex Person ID (PID) Docket Nu mber / / ----------------------------------- Docket Nu mber(s ) (under w hich child was freed, if different) Mother ----------------------------------- Father DATE OF REPORT PREPARATION: / / All information must be current and represent an update of events and circumstances si nce the child was freed for adoption or the previous Per manency He aring Case Name: Law Guardian: CONNECTIONS Case ID: Attorney for DSS/ACS: Local Case #: Agency with Planning Responsibility: Case Manager & Phone: Casework er & Phone: SECTION I. PERMANENCY P LAN S UMMARY Child’s Name Current P ermanency Planning Goal (PPG) PPG/Date Established Anticipated PPG Placement f or adoption Referral for legal guardi anship Permanent placement w ith fit and willing r elative Placement i n another planned living arrangement with significant connection to an adult / / Placement f or adoption Referral for legal guardi anship Permanent placement w ith fit and willing r elative Placement i n another planned living arrangement with significant connection to an adult Date by which it is expected that the cu rrent or anticipated PPG will be accomplished: / / ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 1 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT SECTION II. PERM ANE NCY PLANNING 1. If there is a plan for continuing placement for th e child, descri be the reaso n placement continues to be neces sary and in accordance with the best inter ests and safety of the child. 2. If there is a plan for trial or final discharge in the next six months, specify t he anticipated date and explain why such dischar ge is safe and appropriate. 3. If the per manency plan includes trial or final disch arge from f oster care, d escrib e the D ischarge Plan for the child. Living Arrangement (include location ): Educational/ Vocational P lan: Health Coverage: Follow-up Health/Mental Health Trea tment Plan: O ther: ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 2 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT SECTION III. REASONABLE E FFORTS TO FINAL IZ E PERMANENCY 4. If the child is free for ad option, but not yet placed in an adoptive home: a. Describe t he child-spec ific rec ruitment efforts th at have been made and the outcome of these effor ts. Include whet her the foste r parent(s) ( current and past, as applicable) have been asked t o adopt, and the foster parent (s)’ respons e. b. What further r ecr uitment effo rts are antici pated in the next six months? 5. If the child is age 14 or older and volu ntarily withheld consent to his/her adoption: a. Descri be the facts and circumst ances related to the child’s decision. b. Describ e efforts that have been made to counsel the child about adoption, including explaining possible post-adoption contact with parent(s) and sibling(s) and enabling/arranging c ontact with other young people of sim ilar age who have been adopted. 6. If the child is free and placed in a pre-adoptive home: a. Describe t he reasonable efforts made to facilit ate the adoption of the child and any barriers to finaliz ing the adoption, including any concerns ab out co mpleting the adoption raised by the pre-adoptive parent(s). b. What additional services/assistance is anticipated in the next six m\ onths to facilitate finaliz ing the adoption? ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 3 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT 7. If applicable, has the child’s case been transferr ed to an adoption unit? Yes No NA 8. Com plete the Adoption m ilestones grids below, as applicable. Intent to Adopt Signed Date Signed Adoptive Hom e Study Complete Date Comple ted Adoptive Placement Agree ment Signed Date Signed Yes No / / Yes No / / Yes No / / Criminal History Re cord Check Date Comple ted SCR Data Base Check Date Comple ted Interstat e Com pact on Placement of Children Date Comple ted Yes No / / Yes No / / Yes No / / Document s t hat have been secur ed for finaliz ing the child’s adoption: check all that apply (* Certified) : Birth Parent s Child *order(s) te rminating mother father p arental rights *surrender(s) mother father *consent(s) mother father *death certificate(s) mother father *birth certi ficate, two copies medical re port consent (child over age 14) Adoptive Parent(s) Attorney financial di sclosure affi davit medical re port *marriage certificat e *divorce certificate *death certificate (of adoptive spouse) back-up resource affidavit of readiness financial di sclosure affi davit *certification of service upon OCA 9. Putative Father Regist ry request, if a pplicable. Was a Putative Father Re gistry reques t made? Yes No Date of request: / / Foun d Not Found ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 4 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT 10. Will an adop tion subsidy applic ation be submitted for the child? Yes No If No, explain why not. If Yes, ch eck the status of the Adoption Subsidy Application: All neces sary information submitte d by adoptive parent(s) ---------------- ---------------- ---------------- ---------------- ----- Voluntary agency subm itted to ACS/Social Services Dep artment ---------------- ---------------- ---------------- ---------------- ----- Pending review at ACS/Social Services Department ---------------- ---------------- ---------------- ---------------- ----- ACS/ Social Services D epartment su bmitted to OCFS NYS AS ---------------- ---------------- ---------------- ---------------- ----- Pending review by OCFS NYSAS ---------------- ---------------- ---------------- ---------------- ----- Subsidy rejected/return ed by OCFS NYSAS ---------------- ---------------- ---------------- ---------------- ----- Subsidy resubmitted to OCFS NYS AS ---------------- ---------------- ---------------- ---------------- ----- Subsidy ap proved ---------------- ---------------- ---------------- ---------------- ----- Subsidy denied ---------------- ---------------- ---------------- ---------------- ----- Subsidy denial appeale d ---------------- ---------------- ---------------- ---------------- ----- Hearing decision reache d Date submitted: / / ---------------- ---------------- ---------------- ---------------- - Date submitted: / / OR Not App licable ---------------- ---------------- ---------------- ---------------- - Date review initiated: / / ---------------- ---------------- ---------------- ---------------- - Date submitted to OCFS NYSAS: / / ---------------- ---------------- ---------------- ---------------- - ---------------- ---------------- ---------------- ---------------- - Date rejected/returned: / / ---------------- ---------------- ---------------- ---------------- - Date of resu bmission to OCFS NYSAS: / / ---------------- ---------------- ---------------- ---------------- - Date of approval: / / ---------------- ---------------- ---------------- ---------------- - Date of denial: / / ---------------- ---------------- ---------------- ---------------- - Date of appeal: / / ---------------- ---------------- ---------------- ---------------- - Date of decision: / / Decision: ______ ___ ___ _____ ___ ___ _____ ___ ___ _ If appl icable, specify what, if anyt hing, is causing delay of final subsidy approval, and what action s will be taken to overcome the delay. If applicable, why was the subsidy denied? ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 5 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT For approve d subsidy, check the app licable category and level of rate: Handicapped Basic Special Ex ceptional Hard-To-Place Basic Special 11. Have the adoptive parent(s) retained an attorney? Yes No 12. Has the adoption petitio n been filed? Yes No If Yes, Date of filing: / / Docketed Count y/Court: / Scheduled for hearing on: / / 13. If the perma nency goal is Guardianship or Placement with a Fit and Willin g Relative: a. Describe reasonable efforts made and services provi ded to finaliz e this p lan. Specify the name and relationship of the guardi an or fit and willing relative. b. What services are anticipated in the next six months? ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 6 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT 14. If the perm anency goal is Another Planned Perm anent Living Arrangement: a. Provide t he compellin g reason for determining that it would not be in the best interests of the child to be placed for adoption, pl aced with a legal guardian, or placed with a fit an d willing relative. b. Describ e how this arrangement pr ovides the child with a significant connection to an adult who is willing to be a permanency resource fo r the child. Sp ecify the arrangement and the name of the adult, and describe reasonable efforts made and services provided to finaliz e this p lan. If no adult has as yet been identifi ed, describ e efforts made to identify a permanen cy resourc e. c. What ser vices are anticipated in the next six months? 15. Is the child AWOL? Yes No If yes, desc ribe efforts to locate the child. ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 7 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT SECTION IV. CHILD’S FRE EING FOR ADOPTION AND P LACEMENT(S) 16. Child’s Name Means of Freeing (m ark all that apply) Parent Date Appeal Pending Date Child was Completely Freed for Adoption TPR ---------------- --- Surrender ---------------- --- Death of Parent Mother Father ---------------- ----- Mother Father ---------------- ----- Mother Father / / / / ---------------- -------- / / / / ---------------- -------- / / / / Mother Father ---------------- --- / / # of Changes in Placemen t Since Freei ng or Previous Permanen cy Hearing Child Curre ntly Placed Foster Boarding Home Non-relative Relative Congregate Care Facility Relative (Direct Place ment) Other 17. Provide curr ent informat ion regarding the placement of the child including: the name of the person(s ) with whom the child is placed, if appli cable; chang es in the placement settin g; protecting factors in the current ho me/facility that support the child’s safet y; and how t his setting su pports the least restri ctive, most appropriate placement that address es the n eeds of the ch ild. 18. Is the child p laced out of state? Yes No If Yes, expla in why it is appropriate, neces sary and in the best interest s of the child? ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 8 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT SECTION V. VISITI NG 19. Desc ribe the current visiti ng plan, including whom th e child is visiting (including parents (if there is an approved contact agreement), siblings, grandparents, p ermanen cy resources, etc.), and the frequen cy, duration an d quality of visits. Desc ribe any anticipated modifications to the visiti ng plan in th e next six months, and the reasons therefor. ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 9 of 1 5 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT SECTION VI. SERVI CES P ROVIDED TO CHILD 20. Desc ribe all service s offe red and/or provided to the child since child was fre ed for adoption or the las t permanen cy hearing and the outcomes or progress the child has made. Desc ribe any additional services for t he child anticipated in the next six months. 21. If the child is age 14 or older, describe the Inde pen dent Living Skills Services provided to the child since child was freed for adopti on or the las t permanen cy hearing an d the skills attained. Describe any additional Independe nt Living Ski lls Services a nticipated for the child in the next six months. ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 1 0 of 15 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT SECTION VII. OTHER SE RVI CES 22. Desc ribe any other servic es and assist ance that have been provided to the prospective a doptive parent(s) to expedite the adoption of the child. Describe the plan for post-adoption service s. ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 1 1 of 15 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT SECTION VIII. CHILD’S HEALTH AND W ELL- BEING 23. If applicable, note the following for the child: Significant Chronic Conditions: None Significant Developmen tal Delay: None Mental Health Diagnoses: None Serious Inju ries/ Hospitaliz ation: None Current M edication: None 24. e any other significant information about the child’s current health and well-bein g not include d bove. Describ a f Physical ast Last Appointmen t Last Screening ast Screening ns Up-To-Date Date o Last Date of L Mental Health Appointmen t, if applicable Date of Dental Date of Vision Date of L Hearing Immuni zatio / / / / / / / / / / Yes No Desc ribe any follow-up tre 25. atment or recomme ndat ions for the child, as a result of the above appointments/scr eenings. ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 1 2 of 15 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT SECTION IX. CH ILD’S EDUCATION 26. Provide information on the child’s cu rrent grade level or program, academi c progress a nd achievements, and any other relevant educational inf orm ation. 27. Describe the steps the agency will take during th e next six months to enable prompt delivery of appropriate educational and/or vocational services to th e child in his or her current plac ement or in any proposed placement, if applicable or while on trial or at final di scharge. 28. Complete th e sections ap propriate to the age -level and educational status of the child. a. If the child is under age 3, check which, if any, of the following criteria the child meet s: involved in an indicated case of child abuse or maltreatment suspected to have a disab ility has been found eligible for Early Interv ention Services (EI) pri or to or during foster care If one or more crit eria are met, ch eck the appropriate boxes. Refe rred for EI Refe rral Date Receiving EI Services Not Eligible / / Desc ribe the steps taken t o refer the c hild to Early Interventio n Services, t he status of the refe rral and any services the child is r eceiving. If the child liste d above has not yet been refe rred, exp lain why. b. If the child is eligible for Pre-Kind erg arten (turns age 4 before Dece mb er 1 st), check the appropriate boxes. Pre-K Not Available Pre-K Available Not Enrolled Enrolled If Pre-kinde rgarten is available and the child is NOT enrolled, describe ste ps taken to enroll the child. ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 1 3 of 15 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT c. If the child is age three or older and is suspecte d of having a disability or has been found eligible for Special Education prior to or during foster car e, describ e the status of the refe rral, the Individualized Education Program (IEP) related recommendations and services provided by the school. d. If the child is school age (ages 6-16/1 7, depending on locality) or elects to participate in a program leading to a high school diploma, describe the st eps taken to enroll the child in a progr am or continue in a program leading to a hig h school dipl om a. e. If the child is over age 16/17 (depending on lo cality), and the c hild has elected not to par ticipate in a high school diploma program, describe th e ste ps taken to assist the chil d to become employed and/or to be com e enrolled in an appr opriate vocat ional progra m. ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 1 4 of 15 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05) PERMANE NCY HEARING REP ORT VERIF ICATION STATE OF NEW Y ORK, COUNT Y OF , BEING DUL Y S W OR N, DE POSES AN D SAYS: that I a m employ ed at , as a cas ew orker; that I have (written read) the foregoing perm an ency report and know the contents thereof; that the infor mation is true and com plet e to m y own know ledge, or believed to be true based on inf orm atio n derived from offici al records and/or reports kept in the regular cour se of business by this social servic es district or voluntary authorized agency directly involved in a ssessment and/or service provision t o the individuals that are the subject(s) of this report; that this repor t is a true and com plet e co py of t he report that was mailed to the parties 14 day s prior to the date certain of the per manency hearing. Name: Title: Sworn to bef ore me this da y of Notary Public Co mm issioner of Deeds ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ ___ __ __ ___ __ _ Date Printe d 1 1/10/20 05 4:5 7 PM Page 1 5 of 15 PH-3 Freed for Adoption Indiv idual Child (FINAL 10/25/05)