Form Soc 154b - Agency - Group Home Agreement - Nonminor Dependent Placed By Agency In Group Home Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Initial transition plan summary shall include:
A.
Medical and dental needs, including the medical condition that requires the group home placement after age 19
B.
Psychological/psychiatric issues identified
C. Staffing review summaries
D.
Educational /employment assessment
E.
Peer adjustment
F.
Relationship to staff and other adults identified as potential permanent connections
G. Involvement in recreation programs
H. Behavior problems impacting house rules
I.
Short-term treatment objectives (goals established for next 3 months)
J.
Long-range goals including anticipated length of placement and discharge planning
K.
Tasks planned to reach objectives and goals as defined in the young adult’s TILP and staff who will be performing these
tasks,including agency service activity
L.
Identification of unmet needs
M. Involvement of young adult in the transition program
Periodic update of transition plan:
A.
Current status of young adult’s physical and psychological health. This includes, as applicalbe, the reasons(s) why admission to or
continuation in a group home is the best alternative available to meet the young adult’s special needs
B.
Reassessment of young adult’s adjustment to the group home, program, peers, school and staff
C. Progress toward short-term objectives and long-range goals as defined in the young adult’s TILP including tasks which have been
performed to reach these objectives and goals. This includes as applicable, tasks which have been performed to reach these
objectives and goals and how the placement will contribute to the young adult’s transition to independent living and the treatment
strategies that will be used to prepare the young adult for a less restrictive, more family-like setting.
D.
Reassessment of unmet needs and efforts made to meet these needs
E.
Modification of ttransition plan, tasks to be performed and anticipated length of placement, including the target date for discharge
from the group home placement
F.
Involvement of young adult in transition program
G. Progress of discharge planning
I have read the foregoing and agree to conform to these requirements. The terms of this agreement shall remain in force until
changed by mutual agreement of both parties or when this young adutl is removed from the group home.
SIGNATURE OF PLACEMENT WORKER
SIGNATURE OF AUTHORIZED GROUP HOME REPRESENTATIVE
TITLE
TITLE
NAME OF AGENCY
NAME OF GROUP HOME
ADDRESS
ADDRESS
PHONE
DATE
DATE
PHONE
(
)
(
)
cc: To group home, young adult’s social service record
AGENCY -- GROUP HOME AGREEMENT
Confidential in acordance with
Penal Code Section 11167.5 and/or
WIC Sections 827 and 10850
PAGE 2 of 2
SOC 154B (1/12) REQUIRED FORM - NO SUBSTITUTES PERMITTED
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