Form Soc 156a - Agency - Foster Parents Placement Agreement
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AGENCY - FOSTER PARENTS PLACEMENT AGREEMENT
Nonminor Dependent Placed by Agency in Foster Home
COMPLETE IN DUPLICATE
One copy to
Foster parents
Young adults’ social services
record
The agreement will be initiated when the young adult is placed in the facility and whenever the rate changes.
NAME OF YOUNG ADULT
FOSTER PARENT’S NAME
CASE NUMBER
BIRTHDATE OF YOUNG ADULT
DATE PLACED
ADDRESS (YOUNG ADULT’S PHYSICAL ADDRESS)
Anticipated duration of placement is ________months.
The Agency will pay $ __________ per __________ for the above-mentioned young adult’s care and supervision as defined in Welfare and Institutions
Code 11460 and other applicable law and regulations.
First payment to be within 45 days after placement with subsequent payments no later than the 15th of the month following provision of care. If additional
amounts are to be paid, the reason, the amount and conditions shall be set forth here:
■ ■
■ ■
Special problems/needs:
No
Yes
If yes, explain.
AGENCY AGREES TO:
FOSTER PARENTS AGREE TO:
1.
The placing agency will obtain from the young adult all appropriate
1.
Provide this young adult the nurture, care, clothing, supervisions and
releases of information relevant to this placement in order to provide
assistance to obtain life skills and experiences suited to his or her
the foster parent with knowledge of the background and needs of the
needs.
young adult necessary for effective care. This may include, based on
2.
Develop an understanding of the responsibilities, objectives, and
the young adult’s consent, a social work assessment, medical
requirements of the Agency in regard to the care of this young adult.
reports, educational assessment, and identification of special needs
3.
Notify the placing agency within 24 hours of having knowledge (unless
and the young adult’s TILP. This shall be made available to foster
there is a separate written agreement with the placing agency) by
parents within 14 days from date of placement.
phone followed in writing of significant changes in the young adult’s
2.
Develop a transition plan for the young adult and share pertinent
health, behavior or location as well as significant issues including
aspects with the foster parents.
suspected physical or psychological abuse, death, injury, unusual
3.
Inform the provider, before placement, of this young adult’s behaviors
incidents, unusual absence of a young adult, placement issues,
and proclivities that might be harmful to others (including pets) in the
changes to work or school participation and all items required by
home, school or neighborhood.
approval or licensing standard regulations.
4.
Work with foster parents toward successful completion of the young
4.
Work together with the placing agency to encourage the maintenance
adult’s transition plan, a positive placement outcome and timely
of permanent connections with the young adult’s siblings, other family
permanency for the young adult.
members and significant adults, as indicated in the transition plan,
5.
Work with foster parents in the development and progress of a
and/or by the young adult and family team meetings whenever
transition plan. The county placing agency will notify and invite the
possible.
foster parent to participate in any young adult and family team
5.
Support the young adult in working on the activities for education and
meetings to discuss the young adult’s transition plan.
employment as described in the TILP.
6.
Work together with the foster parents to develop and maintain positive
6.
Use constructive alternative methods of harm reduction, not use
relationships with the young adult’s significant others, siblings and
corporal punishment, or punishment in the presence of others,
other family members.
deprivation of meals, monetary allowances, threat of removal or any
7.
Continue paying for the young adult’s care as long as the young adult
type of degrading or humiliating punishment.
remains in placement or in the temporary absence of the young adult,
7.
Respect and keep confidential information given about the young
when the placing agency asks the provider to retain an open
adult.
placement.
8.
Give the agency prior notice of at least 7 days if removal of the young
8.
Provide procedure for grievances of foster parents.
adult is requested unless it is agreed upon with the agency that less
9.
Contact the young adult and foster parents at least once a month.
time is necessary.
10. Inform the provider of the county clothing allowance policy and pro-
9.
Follow the licensing requirements.
vide the funding consistent with those policies.
10. Provide agency access to required documentation and records
11. Provide arrangements for travel to the young adult’s secondary
maintained for the young adult.
school of origin, as appropriate.
11. Follow any requirements associated with county’s clothing allowance
12. Verify and remit/reconcile any underpayments within 45 days of
policy and procedure.
provider notification of such underpayments.
12. Remit any overpayment in full to the county welfare department upon
13. Notify the provider within 12 months of suspected overpayments, in
receipt of a notice or following the completion of due process.
accordance with applicable laws and regulations.
13. Inform county upon discovery of apparent overpayment.
14. Provide assistance with emergencies. Phone number for after-hours
14. Immediately notify the placing agency of any changes to the young
or weekends is:
adult’s arrangement for educational travel to the secondary school of
origin (if appropriate).
FOSTER PARENT”S NAME
PHONE
(
)
PRINT:
SIGNATURE:
FOSTER FAMILY AGENCY REPRESENTATIVE’S NAME
PHONE
(
)
PRINT:
SIGNATURE:
TITLE:
NAME OF AGENCY:
DATE
A
GENCY - FOSTER PARENTS
Confidential in accordance with
Penal Code Section 11167.5 and/or
PLACEMENT AGREEMENT
SOC 156A (1/12) REQUIRED FORM - NO SUBSTITUTE PERMITTED
WIC Sections 827 and 10850
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