Form Dss-1789 - Voluntary Placement Agreement
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2Voluntary Placement Agreement
I,_______________, the parent/guardian of _____________ request that the
__________County Department of Social Services(DSS) place my child in foster care. This
placement is necessary and in my child’s best interest at the present time because
Before asking for this placement I have tried to provide for this child by
Efforts made by the DSS to prevent this placement, or reasons why no efforts were possible:
I am requesting that this placement last for ____days. I understand that I can terminate this
agreement at any time that I wish to do so. I also understand that the _________DSS can
terminate this agreement if I fail to follow the plan we have developed together. [Attach copy of
Case Plan-Service Agreement]. This agreement may be terminated by either party with 24
hours prior notice. In no case can a VPA continue for more than 90 days without a court review
of the placement. This placement will end on____________________.
I further understand that if, any time, there are concerns about the abuse or neglect of my child,
a protective services investigation will be done. If abuse or neglect is found, I also understand
that a petition may be filed requesting that custody of my child be given to the
__________DSS.
A visitation agreement has been discussed and agreed upon. [Attach copy]
I understand that this is not a legal transfer of custody, but is a time limited transfer of some
parental rights. Specifically, I authorize the DSS to consent to any routine or emergency medical
treatment, mental health treatment and educational evaluations for the above named child. I
retain my parental rights and continue to be responsible for the care and support of my child in
the following ways:
I have/have not discussed this request for placement with the child’s other parent(s).
The DSS will be responsible for the following in order to expedite and support the child’s return
home:
This agreement is to provide placement for:
Child’s Name ________________________DOB_____________________
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