Form Soc 154a - Placement Agency - Foster Family Agency Agreement - Child Placed By Agency In Foster Family Agency
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PLACEMENT AGENCY - FOSTER FAMILY AGENCY AGREEMENT
CHILD PLACED BY AGENCY IN FOSTER FAMILY AGENCY
NAME OF CHILD
FFA NAME
BIRTH DATE OF CHILD
DATE PLACED WITH FFA
CASE NUMBER
DATE FIRST ENTERED FOSTER CARE
The Placement Agency will pay $ ____________ per month in return for the above named child’s care and supervision as defined
in Welfare and Institutions Code 11460 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
FOSTER FAMILY AGENCY AGREES TO
1.
Provide this child with foster parent(s) who have been certified to
1.
Provide the Foster Family Agency (FFA) with
care for the child’s needs in accordance with applicable laws and regulations
knowledge of the background and needs of this child.
and educaitonal stability requirement.
This shall include but not be limited to the social work
assessment, medical reports, educational assess-
2.
Conform to applicable Title 22, Division 6 regulations and all laws governing
ments, psychiatric/psychological evaluations and iden-
foster care.
tification of special needs. This shall be made available
3.
Notify the placing agency within 24 hours (unless there is a separate written
to the FFA within 14 days from date of placement.
agreement with the placing agency) by phone
followed in writing of
2.
Inform the FFA, before placement, of this child’s
significant changes in the child’s health, behavior or location as well as
behaviors and proclivities that might be harmful to
significant issues including suspected physical or psychological abuse,
others (including pets) in the home, school or
death, injury, unusual incidents, absence of a child, placement issues and
neighborhood.
school non-attendance and all items listed under Section 80061 of Title 22,
Division 6.
3. Work with the FFA in the development and progress of a
needs and services plan. The county placing agency
4.
Work together with the placing agency to encourage the maintenance of the
will notify and invite the FFA to participate in any child
familial-child relationship and include the child’s family members, as
and family team meetings to discuss the child’s needs
indicated in the needs and services plan, in treatment planning and/or child
and services plan.
and family teams whenever possible and cooperate with the reunification
process.
4.
Work with FFA staff toward successful completion of
the child’s needs and services plan, a positive
5.
Use constructive alternative methods of discipline; not use corporal
placement outcome and timely permanency for thchild.
punishment; deprivation of meals, monetary allowances, visits from parents,
Provide the FFA a JV 220A, Prescribing Physician’s
or home visits; threat of removal or any degrading or humiliating punish-
Statement, if applicable, and subsequent renewals.
ment.
5.
Work together with the FFA to develop and
6.
Respect and keep confidential information given about this child and his/her
maintain positive relationships with the child’s parents
family.
(or guardians) and other family members, and
7.
Work with the placing agency to develop and submit to them a needs and
cooperate with the reunification process, e.g. provide
services plan that develops an understanding of the responsibilities,
written information regarding a child’s medical and
objectives and requirements of the agency in regard to the care of this child,
transportation needs.
including the information listed on the reverse side of this form, within 30
6.
Maintain contact with the child monthly or as
days of placement of the child. The needs and services plan shall be up-
specified in the child’s approved case plan.
dated at least every six months.
7.
Continue paying for the child’s care as long as the child
8.
Written progress reports shall be provided at least every six months or more
remains in placement or in the absence of the child the
frequently by mutual agreement.
placing agency asks the
FFA to retain an open
9.
Give placing agency 7 day notice of intent to discharge or move this child.
placement.
Notify the placing agency of any intended move of this child between
8.
Provide
a
MediCal
card
or
other
medical
certified homes prior to the move. The FFA has the authority to move a child
coverage and a Medical Consent form signed by the
in the case of imminent risk to the child or family. The FFA shall notify the
child’s parents, legal guardian or court at the time of
placing agency within 24 hours of such move.
placement.
10. FFA social worker shall visit this child in private in their foster home at least
9.
Inform the FFA of its clothing allowance policy and
once per calendar month and provide documentation of these visits to the
provide the funding consistent with those policies or
placing agency caseworker/probation officer on a flow basis every month
any revised policies.
as visits are completed.
10. Pay for medical costs incurred prior to the
11. Provide state and federal agencies access to records as provided by state
establishment of Medi-Cal eligibility.
and federal law.
11. Verify and remit/reconcile any underpayments within 45
12. Notify the placing agency if the child receives any source of income such as
days of FFA notification of such underpayments.
income from work, SSI, SSA, child support, etc. Notify the county of any
property the child obtains, including bank accounts. (It will be the county’s
12. Notify the FFA within 12 months of suspected overpay-
responsibility to verify the income/property.)
ments, in accordance with applicable laws and
regulations.
13. Follow any requirements associated with the county’s clothing allowance
policy and procedures.
13. Provide for arrangements for school of origin travel as
appropriate.
14. Remit any overpayment in full to the county welfare department upon receipt
of a notice of action or following the completion of due process.
14. Provide a contact telephone number for emergencies
and after business hours:
15. Inform county upon discovery of any apparent overpayment.
Emergency #
16. Immediately notify the placing agency of any changes to the child’s
educational travel arrangements (if applicable) including a change in certified
homes.
SOC 154A (12/11) REQUIRED FORM - NO SUBSTITUTES PERMITTED
PAGE 1 OF 2
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