In the matter of 

First and last name(s), alias(es)

1. Date of hearing: 

2. Removal date:  

 

 

 

  Judge/Referee: 

3. 

 Review 

 

 Hearing to extend jurisdiction 

 

 Probation violation hearing

4. As of the last order, dated 
 

 , the juvenile was placed with 

 

 in the temporary custody of the court.

5. Notice of hearing was served as required by law.

 6. The juvenile appeared in court in person with the parent(s), guardian, legal custodian, or guardian ad litem, and
   

  waived representation by an attorney.

  was represented by an attorney. 

 

THE COURT FINDS:

7. Return of the juvenile to his or her parents 
 

juvenile or society.

 

 would 

 

 would not 

  cause a substantial risk of harm to the 

 8. The juvenile 

 

 did 

 

 did not 

  violate probation. Supplemental petitions regarding the violation are dated:

 

 .

 9. There 

 

 is 

 

 is not 

 

reasonable cause to believe that the juvenile violated the following court order(s):

 Name and date of order

 because:

 10.  Restitution has been made as ordered.

 11.  The juvenile has not been rehabilitated.

 12.  The juvenile presents a serious risk to public safety.

 13.  The case service plan has been successfully completed (for use when terminating jurisdiction).

 14.  The juvenile has reached an age no longer within the jurisdiction of the court (for use when terminating jurisdiction).

 15.  The juvenile must be placed in an institution outside Michigan because
      a. institutional care is in the best interests of the juvenile,
      b. equivalent facilities to meet the juvenile’s needs are not available within Michigan, and
      c.  the placement will not cause undue hardship.

 16.  It is contrary to the welfare of the juvenile to remain in the home because:

 17.  Placement of the juvenile in a secure facility is necessary because there is no appropriate less restrictive placement 
      available considering the best interests of the juvenile because:

 

   

 

     

 

 

 

 

 
 
 

 

Reference Note: The term “department” refers to the Michigan Department of Health and Human Services.

Approved, SCAO
Form JC 57, Rev. 12/22
MCL 712A.15, MCL 712A.18, MCL 712A.18a, MCL 712A.18c, 
MCL 712A.18d, MCL 712A.19, MCL 712A.20, MCL 712A.24, 
MCL 722.123a, MCR 3.944,  MCR 3.945
Page 1 of 4

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYSUPPLEMENTAL ORDER OF DISPOSITION/PERMANENCY PLANNING(DELINQUENCY PROCEEDINGS)CASE NO.PETITION NO.JUDGECourt addressCourt telephone no.PCS Code: SDRTCS Code: SDH 
 
 
 
 
 

 
 

 
 
 

 

 

 
 

 
 
 
 
 
 
 

 
 

Supplemental Order of Disposition/Permanency Planning (Delinquency Proceedings) 
Page 2 of 4

(12/22) 

Case No. 
 

 18.  The needs of the child
     
 cannot be met in a foster family home, placement of the child in a qualified residential treatment program provides 
          the most effective and appropriate level of care for the child in the least restrictive environment, and is consistent 
          with the goals in the permanency plan for the child.
     
 can be met in a foster family home, placement of the child in a qualified residential treatment program does not 
          provide the most effective and appropriate level of care for the child in the least restrictive environment, and is 
          not consistent with the goals in the permanency plan for the child.

 a. Reasonable efforts to prevent removal of the juvenile from the home were not made.
 b. Reasonable efforts were made prior to the placement of the juvenile in foster or other out-of-home care, to 

 19. 
     
              prevent or eliminate the need for removing the juvenile from his/her home. Those efforts include:  (Specify.)

 a. Reasonable efforts 

 20. 
              juvenile to safely return to the juvenile’s home. (Specify reasonable efforts below, and if applicable, the reasons for return.)
             
             

 1) Reasonable efforts for reunification should be continued. 
 
 2) Those reasonable efforts were successful and the juvenile should be released to

 were not  made to preserve and reunify the family to make it possible for the

 were 

 

 

 

 

 

                      

Name(s) of parent(s), guardian, or legal custodian

               The reasonable efforts include: (Specify.)

 .

 b. Reasonable efforts to preserve and reunify the family to make it possible for the juvenile to safely return to the

     
              juvenile’s home are not required based on a prior order.

  have not  been made to finalize the court-approved permanency plan of 

  have 
 a. return to the parent, guardian, or legal custodian
 b. adoption 
 c. legal guardianship 
 d. placement with a fit and willing relative 
 e. placement in another planned permanent living arrangement (APPLA) for the child(ren) age 16 or older 

 21.  *Reasonable efforts 
     
     
     
     
     
              due to the compelling reasons that: (Specify the compelling reasons for another planned permanent living arrangement by 
              entering the language that corresponds to the number[s] from the list on the last page.)

       The reasonable efforts made to finalize the court-approved permanency plan identified above include:
       (Specify the permanency plan for each child and the reasonable efforts made toward finalizing that plan.) 

  

 

22. Other findings:

Note: If the juvenile had been previously removed from the home, was then returned to the home, and is being removed again through
this order, contrary to the welfare and reasonable efforts findings must be made even though the findings had been made at a prior
hearing.

*MCL 712A.19a provides that the permanency planning hearing shall not be delayed beyond 12 months from the most recent date of 
removal of the juvenile and every 12 months thereafter.

Supplemental Order of Disposition/Permanency Planning (Delinquency Proceedings) 
Page 3 of 4

(12/22) 

Case No. 
 

IT IS ORDERED:
23.  Prior orders remain in effect except as modified by this order.

 24.  The juvenile is returned to his or her parent(s)/guardian/legal custodian.

 25.  The juvenile shall remain in the 

 

 26.  Pursuant to MCL 712A.18(1)(k), the juvenile’s placement shall not exceed 7 days. This order may not be renewed  
      or extended. The plan for juvenile’s release is as follows:

 

 27.  The juvenile’s placement shall be changed to 

 

 28. The juvenile’s placement in a qualified residential treatment program 

 

 is 

 

 is not 

  approved.

 29. 

 a. The juvenile is referred to the department for placement and care under MCL 400.55(h).

 b. The juvenile is placed in and shall satisfactorily complete the juvenile boot camp program established by the 

     
              department. After satisfactorily completing the program, the juvenile shall be placed in the home of 

             
 
              and shall complete a minimum of 120 to a maximum of 180 days of intensive supervised probation in the 
              community.

 

 c.  The juvenile is committed to the department under MCL 803.301 (Y.R.A.). The director of the department is 

     
              appointed special guardian to receive any benefits now due or to become due to the juvenile from the 
              government of the United States. Pending transfer to the department, temporary placement is as follows:

 specified in a separate order of probation.
 30.  The juvenile is placed on probation. Probation terms are 
 31.  The jurisdiction of this court is terminated in this case except that the court reserves the right to enforce payments of
      support and attorney fees that have accrued up to and including the date of this order.
 32.  Jurisdiction is extended until the juvenile reaches the age of 21.

 attached. 

33.  Previous reimbursement orders shall continue.
34.  Other:

  35. The next review hearing is 

Date and time

 .

  36. IT IS RECOMMENDED: (Use in cases where applicable.)

       

  The juvenile shall remain in the 

 

       

  The juvenile’s placement shall be changed to 
 

 

                     

Recommended by:

Referee signature and date

 

                     

Judge signature and date

 .

 .

 .

 .

  

 

 
 
 

 
 
 

 

 

   

Supplemental Order of Disposition/Permanency Planning (Delinquency Proceedings) 
Page 4 of 4

(12/22) 

Case No. 
 

The following are examples of compelling reasons for a permanency plan other than return to parent, legal 
guardianship, placement with a fit and willing relative, or adoption.
1. No relative has been identified who is appropriate or available to assume the permanent custody of the child.
2. The current caregiver is not an adoptive resource.
3. Reasonable efforts to recruit an adoptive home have been unsuccessful.
4. The child does not want to be adopted and is of an age where due consideration must be given to his/her wishes.
5. It is contrary to the child’s best interests to break the child’s attachment to the current caregivers.
6. The current caregiver is committed to providing a permanent placement for the child.
7. The placement allows the siblings to remain together.
8. The child’s special needs can best be met in this placement.
9. The child wants to remain in the current placement, which is only available as foster care.
10.  The placement is preparing the child for transition into independent living (specify the services being provided to the 
 
 
 
 
11.  The child comes under the Indian Child Welfare Act and Michigan Indian Family Preservation Act, and the child’s tribe
 
12.  Other (specify in the findings in item 21e).

  child to assist with transition such as referral to an independent living skills program, enrollment in a vocational program, 
  referral for a mentor, continued out-of-home placement in foster care beyond age 18 to allow the child to complete 
  secondary school, placement in a resource that provides on-site training for independent living, and other similar 
  services).

  recommends permanent placement in long-term foster care.