PERMANENCY HEARING REPORT PERMANENCY HEARING DATE CERTAIN: Judge / Referee Court // Part IN THE MATTER OF: Child's Name Date of Birth / / Sex Person ID (PID) Docket Number ----------------------------------- Docket Number(s) (under which child was freed, if different) Mother ----------------------------------- Father DATE OF REPORT PREPARATION: / / All information must be current and represent an update of events and circumstances since the child was freed for adoption or the previous Permanency Hearing Case Name: CONNECTIONS Case ID: Local Case #: Case Manager & Phone: Law Guardian: Attorney for DSS/ACS: Agency with Planning Responsibility: Caseworker & Phone: SECTION I. PERMANENCY PLAN SUMMARY Child's Name Current Permanency Planning Goal (PPG) Placement for adoption Referral for legal guardianship Permanent placement with fit and willing relative Placement in another planned living arrangement with significant connection to an adult PPG/Date Established / / Anticipated PPG Placement for adoption Referral for legal guardianship Permanent placement with fit and willing relative Placement in another planned living arrangement with significant connection to an adult / / Date by which it is expected that the current or anticipated PPG will be accomplished: ______________________________________________________________________________________________________ Date Printed 11/10/2005 4:57 PM Page 1 of 15 PH-3 Freed for Adoption Individual Child (FINAL 10/25/05) American LegalNet, Inc. www.USCourtForms.com PERMANENCY HEARING REPORT SECTION II. PERMANENCY PLANNING 1. If there is a plan for continuing placement for the child, describe the reason placement continues to be necessary and in accordance with the best interests and safety of the child. 2. If there is a plan for trial or final discharge in the next six months, specify the anticipated date and explain why such discharge is safe and appropriate. 3. If the permanency plan includes trial or final discharge from foster care, describe the Discharge Plan for the child. Living Arrangement (include location): Educational/Vocational Plan: Health Coverage: Follow-up Health/Mental Health Treatment Plan: Other: ______________________________________________________________________________________________________ Date Printed 11/10/2005 4:57 PM Page 2 of 15 PH-3 Freed for Adoption Individual Child (FINAL 10/25/05) American LegalNet, Inc. www.USCourtForms.com PERMANENCY HEARING REPORT SECTION III. REASONABLE EFFORTS TO FINALIZE PERMANENCY 4. If the child is free for adoption, but not yet placed in an adoptive home: a. Describe the child-specific recruitment efforts that have been made and the outcome of these efforts. Include whether the foster parent(s) (current and past, as applicable) have been asked to adopt, and the foster parent(s)' response. b. What further recruitment efforts are anticipated in the next six months? 5. If the child is age 14 or older and voluntarily withheld consent to his/her adoption: a. Describe the facts and circumstances related to the child's decision. b. Describe 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 contact with other young people of similar age who have been adopted. 6. If the child is free and placed in a pre-adoptive home: a. Describe the reasonable efforts made to facilitate the adoption of the child and any barriers to finalizing the adoption, including any concerns about completing the adoption raised by the pre-adoptive parent(s). b. What additional services/assistance is anticipated in the next six months to facilitate finalizing the adoption? ______________________________________________________________________________________________________ Date Printed 11/10/2005 4:57 PM Page 3 of 15 PH-3 Freed for Adoption Individual Child (FINAL 10/25/05) American LegalNet, Inc. www.USCourtForms.com PERMANENCY HEARING REPORT 7. If applicable, has the child's case been transferred to an adoption unit? Yes No NA 8. Complete the Adoption milestones grids below, as applicable. Intent to Adopt Signed Yes No Date Signed Adoptive Home Study Complete Yes No Date Completed Adoptive Placement Agreement Signed Yes No Interstate Compact on Placement of Children Yes No Date Signed / / / / / / Criminal History Record Check Yes No Date Completed SCR Data Base Check Yes No Date Completed Date Completed / / / / / / Documents that have been secured for finalizing the child's adoption: check all that apply (*Certified): Birth Parents Child *order(s) terminating mother father *birth certificate, two copies parental rights medical report *surrender(s) mother father consent (child over age 14) *consent(s) mother father *death certificate(s) mother father Adoptive Parent(s) financial disclosure affidavit medical report *marriage certificate *divorce certificate *death certificate (of adoptive spouse) back-up resource 9. Putative Father Registry request, if applicable. Was a Putative Father Registry request made? Yes Date of request: / / Found No Not Found Attorney affidavit of readiness financial disclosure affidavit *certification of service upon OCA ______________________________________________________________________________________________________ Date Printed 11/10/2005 4:57 PM Page 4 of 15 PH-3 Freed for Adoption Individual Child (FINAL 10/25/05) American LegalNet, Inc. www.USCourtForms.com PERMANENCY HEARING REPORT 10. Will an adoption subsidy application be submitted for the child? Yes If No, explain why not. No If Yes, check the status of the Adoption Subsidy Application: All necessary information submitted by adoptive parent(s) --------------------------------------------------------------------Voluntary agency submitted to ACS/Social Services Department --------------------------------------------------------------------Pending review at ACS/Social Services Department --------------------------------------------------------------------ACS/ Social Services Department submitted to OCFS NYSAS --------------------------------------------------------------------Pending review by OCFS NYSAS --------------------------------------------------------------------Subsidy rejected/returned by OCFS NYSAS --------------------------------------------------------------------Subsidy resubmitted to OCFS NYSAS --------------------------------------------------------------------Subsidy approved --------------