Form Soc 156 - Agency - Foster Parents Agreement - Child Placed By Agency In Foster Home
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AGENCY - FOSTER PARENTS AGREEMENT
Complete in Duplicate:
One copy to:
Foster parents
Child Placed by Agency in Foster Home
Child’s Social
The agreement will be initiated when the child is placed
Service Record
in the facility and whenever the rate changes.
NAME OF CHILD
PARENT’S NAME
BIRTHDATE OF CHILD
DATE PLACED
CASE NUMBER
FOSTER PARENT’S NAME
ADDRESS
Anticipated duration of placement is ________ months.
The agency will pay $ __________ per __________ for room and board, clothing, personal needs, recreation, transportation, education, incidentals and
supervision. 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, amount and conditions shall be set forth here:.
I I
I I
Special problems/needs:
No
Yes
If yes, explain.
Special Permissions: Special permission for substitute supervision is subject to Community Care Licensing granting an exception to the licensing
regulation, which requires that substitute supervision in the foster home be limited to an adult.
I I
Child 15 years or older has permission to remain without adult supervision during temporary absences of the the foster parent(s), not to exceed
six (6) consecutive hours in any one 72-hour period.
I I
Substitute supervision may be provided to the foster child by someone 16 years of age or older (not a foster child) during temporary absences of the
foster parent(s), not to exceed six (6) consecutive hours in any one 72-hour period.
I I
Other (Explain)
I I
No special permissions granted.
AGENCY AGREES TO
FOSTER PARENTS AGREE TO
1. Provide the foster parent with educational stability requirement, school
1. Provide this child the nurture, care, clothing and training suited to his
needs.
of origin and travel plan, knowledge of the background and needs of
2. Develop an understanding of the responsibilities, objectives, and
the child necessary for effective care. This may include a social work
requirements of the Agency in regard to the care of this child.
assessment, medical reports, education assessment, and identification
3. Recognize the Agency's responsibility for planning for this child, as
of special needs when necessary. This shall be made available to fos-
given by the court or the parent(s).
ter parents within 14 days from date of placement.
4. Recognize any limitations of consent imposed by the court or the
2. Develop a plan for the child and share pertinent aspects with the
parent.
foster parents.
5. Increase their knowledge and ability to care for this child.
3. Inform foster parents they may give the same consents on behalf of
6. Encourage the child’s relationships with his parents and relatives.
7. Cooperate in visiting arrangements between child and parents.
the child as the parent, except for those prohibitions provided in Social
8. Not use corporal punishment, punishment in the presence of others,
Services Manual Regulations.
deprivation of meals, monetary allowances, visit from parent, home
4. Not remove the child with less than 7 calendar days written notice
visits, threat of removal or any type of degrading or humiliating
unless: the child is physically or psychologically endangered; court
punishment, and to use constructive alternative methods of discipline.
orders removal; parents or guardians order removal (voluntary place-
9. Respect and keep confidential information given about the child and
ment); signed waiver obtained from foster parents; removal is from an
his family.
interim placement directly into an adoptive home.
10. Immediately notify agency of significant changes in this child’s health,
5. Involve foster parents in future planning for the child. The placement
behavior, or location.
11. Accept the child’s special problems as given above in my provision of
shall be reviewed within 6 months.
care.
6. Assist the child in his use of foster care.
12. Help with termination of placement including return to his own parents,
7. Assist in the maintenance of the child’s constructive relationships with
relatives home, or adoptive placement.
parents and other family members and to involve parents in future
13. Give the agency prior notice of at least 7 days if removal of child is
planning for this child.
requested unless it is agreed upon with the agency that less time is
8. Provide procedure for grievances of foster parents.
necessary.
9. Contact the child and foster parents at least once a month. If case
14. Conform to the licensing/certification requirements.
plan would indicate less frequent contacts, the foster parent will be
15. Provide state and federal agencies access to documentation when
documentation is maintained on children in their care.
informed.
16. Give advance written notice to the licensing agency and the person or
10. Inform foster parents if child has any tendencies toward dangerous
agency responsible for the child of any (foster parent(s)) absence of
behavior.
48 hours or longer. (Absence may be reported by telephone in case
11. Provide Medi-Cal card or other medical coverage at time of placement.
of emergencies.)
Arrange for medical examination within 30 days unless child has had
17. Notify the agency immediately if an application is made on behalf of
such within past 6 months and information is available.
this child for any kind of income. Examples of income include, but are
12. Provide a clothing allowance as permitted to meet initial clothing
not limited to, child support payments, Veterans Benefits, Railroad
needs.
Retirement, Social Security, RSHDI, and Supplemental Security
Income/State Supplemental Program (SSI/SSP).
13. In cooperation with foster parents arrange for visiting by parents or
18. Remit to Department of Public Social Services any income received
relatives on:_____________________________________________.
on behalf of this child while in foster care up to the full cost of board
14. Provide arrangements for school of origin travel as appropriate.
and care plus medical cost. In addition, I will cooperate to have the
15. Provide assistance with emergencies. Telephone number for after-
Social Security Administration, or the appropriate agency, make the
hours or weekends is: _______
__________________________________.
Department of Public Social Services the payee for any funds received
on behalf of this child.
19. Foster parent agrees to immediately notify the placing agency of any
*See Next Page for Optional Long-Term Placement Intent
changes to the child’s educational travel, withdrawal from school or
graduation.
SOC 156 (12/11) REQUIRED FORM - NO SUBSTITUTE PERMITTED
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