Pathway of Hope
PO Box 1128
Evart, Michigan 49631
Name of Ward D.O.B.SexAgeGrade
Home Address City State Zip Code
Place of Birth Soc. Sec. # ______
Religious Preference ______
School Last AttendedAddress _____
Color of Eyes Hair Weight Height Race_____
Special Medical Needs (allergies, etc.)
II. Referring Agency
Agency’s Name Address
Worker’s Name Title
Phone #: Committing County
- 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 # ______E-Mail______
Mother’s Name: Step-Father/LTP:
Phone #: (H) (W) (Mess)
SS # ______E-Mail______
Marital Status of Both Parents:
Do Both Parents Have Parental Rights Yes No If no, explain:
Concerned Relatives Phone: Relationship:
Name: Phone: Relationship:
Professional Contact List
Will the resident be eligible for a clothing order while in placement at Muskegon River Pathway of Hope?
If yes please answer the following questions:
Date of last clothing order?______
Date of next clothing order?______
Amount of next clothing order?______
Please list the names, Phone Numbers, and Addresses of the people the resident is allowed to have contact with.
Resident’s Name: ______
County that resident is from: ______
Permanent or temporary ward of the state? ______
Worker’s Name: ______
Who is responsible for paying the billing? ______
- Title 4E
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
Muskegon River Pathway of Hope
Cash Release to Accounts Payable
Any Resident that has an outstanding court fee or property damage fee will be required to pay ½ of their earned rewards income towards their amount due. This will continue until the debt is paid full. The Resident will get a print out at the end of each month listing payments made and the balance that is owed.
Designee Signature ______
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
- What is the name and address of the resident’s attorney?
- Will the resident be eligible for a clothing order while in placement at Pathway?
If Yes, please answer the following questions:
Date of Last Clothing Order: ______
Date of Next Clothing Order: ______
Amount of Next Clothing Order: ______
- Please list the names, phone numbers, and addresses of people that the resident is allowed to have contact with:
- Do you give permission for the Case Manager, Supervisor, and Director to screen
all incoming and outgoing mail? Yes No
- What is the date of the next scheduled Court Hearing? ______
- Are there any Court Fees/Fines due? Yes No
If Yes, what is the amount? ______
Application for Acceptance to
Muskegon River 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
Telephone #: Parent/Guardian
Telephone #: Referred by: FIACourt 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)
Height: Weight: Eye Color: Hair Color
Hobbies and Interests:
Other Pertinent Information:
Are your immunizations up to date? Yes No
Do you have any allergies? Yes No
If yes, list:
List any medications you take:
MedicationDosageReason 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 #:
Brothers and Sisters – List including stepbrothers and stepsisters
Living at Home
Living at Home
City, State, Zip
Date of Birth/Age
Place of Birth
County of Divorce
Custody Granted to
City, State, Zip
Family Yearly Income
Social Security No.
If Deceased, Date, Cause
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)
AlcoholHallucinogenic (Acid, LSD…)Morphine
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
To escape reality
To be in with the crowd
Habit cost per day? Longest period clean?
Date of EntryProgram NameCity/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?
Mail Agreement/Permission Form
I, ______, placing worker for
______, resident at Pathway of Hope, give
Pathway of Hope permission for the following employees to open and read all incoming and
Outgoing mail: Pathway of Hope Director, Case Managers, Supervisor and Administrative Assistant.
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 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.
Pathway of Hope Worker:______
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; ______
PATHWAY OF HOPE WORKER; ______
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: ______.
- 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 Completed / Dates Attended / Special Education / Special Ed. Eligibility (EI, LD, OHI)
- Please check if there are any school related problems in the following areas:
____Lack of Coordination____Physical/Verbal Aggression
____Lack of Retention____Disruptive Behaviors____Comprehension
____Work not Completed____Other (Please Describe): ______
- Please check all areas in education that are successful for this student:
____Academic Classes____Extra Curricular (Sports)
____Vocational Experiences ____Art, Music, Drama, etc.
EDUCATIONAL PLANNING CONSENT
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 child/ward.
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 Hope.
Parent/Guardian (Where Applicable) Date
Angela Montgomery, BA Date
Pathway of Hope Director
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.
DHS Worker/Probation OfficerDate
Parent or Guardian (when necessary)
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 activities.
Signature of SubjectDate
If subject is a minor, signature Date
of parent or guardian
If subject is a state or court ward,Date
signature of caseworker
Consent for Physical Intervention
I, ______, give permission to Pathway of Hope to use Emergency
Safety Interventions on my child______while they are part of the program at Pathway. Safety Interventions include Physical Interventions and Time-outs. I understand I will be notified every time a physical intervention is used. All staff are JKM trained, and continue training annually.
DHS Worker/Probation OfficerDate
Case Manager Date
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# ______
WitnessParent or Legal Guardian
Consent for Medication Decisions and Distribution
Resident Name: ______
Pathway of Hope will make every effort to contact the parent and/or placing worker prior to implementing any prescribed medication change ordered by the consulting physician and/or clinician/psychiatrist. When a parent is unavailable or unwilling to provide consent and a child’s physician or psychiatrist have determined there is a medical necessity for the medication, Pathway of Hope will file a motion with the Court requesting consent for the prescription and use of necessary psychotropic medication, as required by DHS. (Courts are provided this authority pursuant to MCL 712.A12 and MCL 712.A13a (7)(c) prior to adjudication and MCL 712A.18(1)(f) and MCL712A (1) at initial or supplemental disposition)
____ I give permission to Pathway of Hope to make decisions regarding medication.
____ I give permission to Pathway of Hope to distribute medications as prescribed.
____ I give permission to Pathway of Hope to distribute over the counter medication for cough and cold symptoms, fever, headache, and basic medical needs.
PLAN FOR EMERGENCY DISCHARGE OF RESIDENT
Resident Name: ______
Placing Agency: ______
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
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)
Dawn Kruithoff –Director Angela Montgomery, BA Assistant Director
Hair GroomingPolicy and Permission
Privately contracted licensed cosmetologists will provide the following cosmetology service needs for youth placed at MRPOH:
- Hair Cuts/Trims
- Instruction for proper hair grooming and styling for all ethnicities and cultures
Youth are expected to keep their hair neatly groomed during awake hours while placed in the program. Youth will be provided with the basic supplies for all hygiene needs, including hair grooming.
Youth placed at MRPOH may to purchase hair extensions/weave/tracks and supplies from the MRPOH Rewards store. However, each youth will be responsible to place them in their own hair.
Youth placed at MRPOH may choose to cut and color their hair during home visits with the permission of their parent/guardian. Placing workers may provide special permission for hair color for youth who do not have an identified parent/guardian and/or that do not have visitation with anyone outside of the facility.
Additional grooming items may be purchased from Rewards store. Youth may also purchase a professional hair/salon appointment from the Rewards store.
Parents/workers must provide written permission to the agency prior to providing cosmetology services to any youth.
By signing below I acknowledge that I have read and understand the MRPOH Policy on hair grooming. I give permission to MRPOH to utilize a licensed cosmetologist to provide basic hair care while the youth is in placement.
Special Instructions and/or additional comments:
MRPOH Case ManagerDate