Form Soc 153 - Placement Agency - Foster Family Agency Agreement - Nonminor Dependent Placed By Agency In Foster Family Agency Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Initial needs and services plan summary shall include:
A.
Medical and Dental needs
B.
Psychological/psychiatric issues identified
C. Staffing review summaries
D.
Educational and employment assessment
E.
Peer adjustment
F.
Relationship to adults identified as potential permanent connections
G. Involvement in recreation program
H. Behavioral problems impacting house rules
I.
Short-term treatment objectives (goals established for next 3 months)
J.
Long-range goals including anticipated length of placement
K.
Tasks planned to reach educational and employment objectives and goals as defined in the young adult’s TILP and 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 needs and services plan shall include:
A.
Current status of young adult’s physical and psychological health as well as confirmation of medical and dental exams
B.
Reassessment of young adult’s adjustment to the foster home, transition program, peers and school/work
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
D.
Reassessment of unmet needs and efforts made to meet these needs
E.
Modification of transition plan, tasks to be performed and anticipated length of placement
F.
Involvement of young adult in transition program
By this signature I attest that I have read this agreement and agree to fulfill these requirements and I am authorized on behalf of my agency to
sign this. The terms of this agreement shall remain in force until changed by mutual consent, in writing, of both parties.
YOUNG ADULT’S PLACEMENT WORKER’S NAME
PHONE
PRINT:
SIGNATURE:
(
)
COUNTY AND NAME OF AGENCY
TITLE
DATE
FOSTER FAMILY AGENCY REPRESENTATIVE’S NAME
PHONE
(
)
PRINT:
SIGNATURE:
TITLE
NAME OF AGENCY
DATE
SOC 153 (1/12)
PAGE 2 OF 2

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