Form Soc 152 - Placement Agency - Thp Plus Foster Care Provider Agreement - Nonminor Dependent Placed By Agency In Thp Plus Foster Care Provider
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1
2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PLACEMENT AGENCY -- THP PLUS FOSTER CARE PROVIDER AGREEMENT
NONMINOR DEPENDENT PLACED BY AGENCY IN THP PLUS FOSTER CARE PROVIDER
NAME OF YOUNG ADULT
THP PLUS FC PROVIDER NAME
BIRTH DATE OF YOUNG ADULT
DATE PLACED WITH THP PLUS FC PROVIDER
CASE NUMBER
DATE FIRST ENTERED FOSTER CARE AS YOUNG ADULT
The Placement Agency will pay $ ____________ per month in return for the above-named young adult’s care and supervision as
defined in Welfare and Institutions Code 11403.2 and other applicable law and regulations. First payment to be made within 45
days after placement with subsequent payments to be made monthly.
PLACEMENT AGENCY AGREES TO
THP PLUS FOSTER CARE PROVIDER AGREES TO
1.
The placing agency will obtain from the young adult
1.
Provide this young adult with a transitional housing site that has
all appropriate releases of information relevant to
been certified to care for the young adult’s needs in accordance
this placement in order to provide the THP PLUS
with applicable laws and regulations.
Foster Care provider with knowledge of the
2.
Conform to applicable approval standards regulations and all
background and needs of this young adult. This may
laws governing foster care.
include, based on the young adult’s consent, a social
3.
Notify the placing agency within 24 hours of the provider having
work assessment, medical reports, educational
knowledge (unless there is a separate written agreement with the
assessment psychiatric/psychological evaluations,
placing agency) by phone followed in writing of significant
identification of special needs, and the young adult’s
changes in the young adult’s health, behavior or location as
TILP. This shall be made available to the provider
well as significant issues including suspected physical or
within 14 days from date of placement.
psychological abuse, death, injury, unusual incidents, unusual
absence of a young adult, placement issues, changes to work or
2.
Inform the provider, before placement, of this young
school participation and all items required by approval standard
adult’s behaviors and proclivities that might be
regulations.
harmful to others.
4.
Work together with the placing agency to encourage the
maintenance of permanent connections with the young adult’s
3.
Work with the provider in the development and
family members, and other significant adults, as indicated in the
progress of a transition plan. The county placing
transition plan, and/or young adult and family teams whenever
agency will notify and invite the provider to
possible.
participate in any young adult and family team
5.
Use constructive alternative methods of harm reduction; not use
meetings to discuss the young adult’s transition plan.
corporal punishment; deprivation of meals, monetary al-
4.
Work
with
provider
staff
toward
successful
lowances, threat of discharge or any degrading or humiliating
completion of the young adult’s needs and services
punishment.
plan, a positive placement outcome and timely
6.
Respect and keep confidential information given about this
permanency for the young adult.
young adult.
7.
Work with the placing agency to develop and submit to them
5.
Work together with the provider to develop and
a transition plan that develops an understanding of the
maintain positive relationships with the young adult’s
responsibilities, objectives and requirements of the agency in
siblings, and other family members.
regard to the care of this young adult, including the information
listed on the reverse side of this form, within 30 days of
6.
Maintain monthly contact with the young adult.
placement of the young adult. The transition plan shall be up-
7.
Continue paying for the young adult’s care as long as
dated at least every six months.
the young adult remains in placement or in the
8.
Written progress reports on the transition plan progress shall be
temporary absence of the young adult, when the
provided at least every six months or more frequently by mutual
placing agency asks the provider to retain an open
agreement.
placement.
9.
Give placing agency 7 day notice of intent to discharge or move
this young adult. Notify the placing agency of any intended move
8.
Provide the young adult with his or her Medi-Cal card
of this young adult between certified sites prior to the move. The
or proof of other medical coverage.
provider has the authority to move a young adult in the case of
imminent risk to the young adult or others in the household. The
9.
Inform the provider of the county clothing allowance
provider shall notify the placing agency within 24 hours of such
policy and provide the funding consistent with those
move.
policies.
10. Provider social worker shall visit this young adult in private in
11. Verify and remit/reconcile any underpayments
their site at the frequency specified in the provider’s plan of
within 45 days of provider notification of such
operation.
underpayments.
11. Provide state and federal agencies access to records as provided
by state and federal law.
12. Notify the provider within 12 months of suspected
12. Follow any requirements associated with the county’s clothing
overpayments, in accordance with applicable laws
allowance policy and procedures.
and regulations.
13. Remit any overpayment in full to the county welfare department
upon receipt of a notice of action or following the completion of
13. Provide arrangements for educational travel to the
due process.
young adult’s secondary school of origin, as
14. Inform county upon discovery of any apparent overpayment.
appropriate.
15. Immediately notify the placing agency of any changes to the
14. Provide a contact telephone number for emergencies
young adult’s secondary educational travel plans (if appropri-
and after business hours:
ate).
Emergency #
SOC 152 (1/12) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PAGE 1 OF 2
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