Form Soc 154 - Agency - Group Home Agreement - Child Placed By Agency In Group Home

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
AGENCY --- GROUP HOME AGREEMENT
Child Placed by Agency in Group Home
Name of Child
Parent’s Name
Date Placed
d
Birthdate of Chil
Case Number
Anticipated duration of placement is
months.
The agency will pay $
per
for room and board, clothing, personal needs, recreation, transportation, education,
incidentals, supervision and social services. First payment to be made within 45 days after placement with subsequent payments to be made monthly.
If additional amounts are to be paid, the reason, amount and conditions shall be set forth here:
I I
I I
Special problems:
Yes
No
If yes, explain.
Agency Agrees To
Group Home Agrees To
1.
Provide the group home with knowledge of the background and needs of
1
.
P r ov i d e th i s c h i l d w i th th e nu r tu r e, c a r e tr e a tm ent a nd
training suited to his needs.
the child necessary for effective care. This shall include a social work,
2.
Follow admission requirements related to medical screening, physical
medical reports, educational assessments, psychological/
examination, medical testing and immunization.
psychiatric evaluations, and identification of special needs when
3. Develop an understanding of the responsibilities, objectives and
necessary. This shall be made available to group home within 14 days
requirements of the agency in regard to the care of this child and work
from date of placement.
with the agency in plan ning for this child.
2.
Work with the group home toward development of a treatment plan.
4. Encourage the maintenance of the natural parent-child relationship
3.
Work toward termination of child’s placement with group home staff.
and include the child’s parents in the treatment plan when possible.
4.
Continue paying for this child’s care as long as eligible and the group
5.
Not use corporal punishment, punishment before the group, deprivation
home maintains child on an active status or until the agency requests
of meals, monetary allowances, visits from parents, home visits, threat
of removal or any type of degrading or humiliating punishment and to
that placement be terminated.
use constructive alternative methods of discipline.
5.
Assist in the maintenance of this child’s constructive relationships with
6.
Respect and keep confidential information given about the child and
parents and other family members and to involve parents in future
his family.
planning for this child.
7.
Work toward termination of placement on a planned basis with
6.
Contact this child in the group home at least once a month. If case
maximum involvement of the child, parents and the agency.
plan would indicate less frequent contact, the group home will be
8.
Conduct a staffing or review on this child at least quarterly.
informed.
9. Submit an initial diagnostic summary to the agency within three (3)
7.
Informed group home if child has any tendencies toward dangerous behavior.
months from the date of placement. This summary shall include
8.
Provide a Medi-Cal card or other medical coverage at the time of
information listed on the reverse side of this agreement form.
10. Submit ongoing written evaluations to the agency quarterly. These
placement.
evaluations shall include information listed on the reverse side of this
9.
Provide authorization for medical treatment, signed by this child’s
agreement form.
parent or legal guardian.
11. Immediately notify agency of significant changes in this child’s health,
10. Provide a clothing allowance as permitted to meet initial clothing needs.
behavior or location.
11. Provide assistance with emergencies. Telephone number for after-hours
12. Submit copies of any pertinent information such as school reports,
or weekends is:
medical reports and psychological/psychiatric reports as completed.
13. Give agency prior notice of at least 7 days of intent to discharge this
child unless it is agreed upon with the agency that less notice is necessary.
14. Conform to the licensing requirements.
15. Provide state and federal agencies access to documentation when
documentation is maintained on children in their care.
16. Notify the agency immediately if an application is made on behalf of
this child for any kind of income. Examples of income include, but
a r e n o t l i m i te d to, c h i l d s u p p o r t p ay me n ts, Ve t eran s B en ef i t s,
Railroad Retirement, Social Security, RSHDI, and Supplemental Security
Income/State Supplemental Program (SSI/SSP).
17. Remit to Department of Public Social Services any income received on
behalf of this child while in foster care up to the full cost of board and
c a r e p l u s m e d i c a l c o s t. In a d d i ti o n , I w i l l c o o p erat e t o h ave
the Social Security Administration, or the appropriate agency, make the
Department of Public Social Services the payee for any funds received
on behalf of this child.
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 this child is removed from the group home.
Signature of Children Placement Worker
Signature of Authorized Group Home Representative
Name of Agency
Title
Name of Group Home
Title
Address
Address
Phone Number
Date
Phone Number
Date
cc:
To group home, child’s(ren) social service record.
Page 1 of 2
SOC 154 (6/00) Required Form -- No Substitute Permitted

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