Form Soc 153 - Placement Agency - Foster Family Agency Agreement - Nonminor Dependent Placed By Agency In Foster Family Agency
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1
2CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
PLACEMENT AGENCY --- FOSTER FAMILY AGENCY AGREEMENT
NONMINOR DEPENDENT PLACED BY AGENCY IN FOSTER FAMILY AGENCY
NAME OF YOUNG ADULT
FFA NAME
BIRTHDATE OF YOUNG ADULT
DATA PLACED WITH FFA
CASE NUMBER
DATE FIRST ENTERED FOSTER CARE
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 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.
The placing agency will obtain from the young adult all appropriate
1.
Provide this young adult with foster parents who have been certified to
releases of information relevant to this placement in order to provide the
care for the young adult’s needs in accordance with applicable laws
Foster Family Agency (FFA) with knowledge of the background and
and regulations.
2.
Conform to applicable Title 22, Division 6 regulations and all laws
needs of this youth. This may include, based on the young adult’s
consent, a social work assessment, medical reports, educational
governing foster care.
3.
Notify the placing agency within 24 hours of the provider having
assessments, psychiatric/psychological evaluations identification of
knowledge (unless there is a separate written agreement with the
special needs and the youth’s TILP. This shall be made available to the
placing agency) by phone followed in writing of significant changes in
FFA within 14 days from date of placement.
the young adult’s health, behavior or location as well as significant
2.
Inform the FFA, before placement, of this young adult’s behaviors and
issues including suspected physical or psychological abuse, death,
proclivities that might be harmful to others.
injury, unusual incidents, unusual absence of a young adult, placement
3.
Work with the FFA in the development and progress of a needs and
issues and the provider having knowledge of significant changes in
services plan. The county placing agency will notify and invite the FFA
work or school participation and all items listed under Section 80061 of
to participate in any young adult and family team meetings to discuss
Title 22, Division 6.
the young adult’s needs and services plan.
4.
Work together with the placing agency to encourage the maintenance
4.
Work with FFA staff toward successful completion of the young adult’s
of permanent connections with the young adult’s siblings, family
needs and services plan, a positive placement outcome and timely
members and tribes, as indicated in the needs and services plan, in
permanency for the young adult.
treatment planning including youth and family teams whenever possible
5.
Work together with the FFA to develop and maintain positive
.
relationships with the young adult’s significant others, siblings and other
5.
Use constructive alternative methods of harm reduction; not use
family members,.
corporal punishment; deprivation of meals, monetary allowances, visits
6.
Maintain monthly contact with the young adult.
from parents, or home visits; threat of removal or any other degrading
7.
Continue paying for the young adult’s care as long as the young adult
or humiliating punishment.
remains in placement or in the temporary absence of the young adult,
6.
Respect and keep confidential information given about this young adult.
when the placing agency asks the FFA to retain an open placement.
7.
Work with the placing agency and young adult to develop and submit to
8.
Provide the young adult with his or her MediCal card or other medical
them a needs and services plan that develops an understanding of the
coverage.
responsibilities, objectives and requirements of the agency in regard to
9.
Inform the FFA of the county clothing allowance policy and provide the
the care of this young adult, including the information listed on the
funding consistent with those policies.
reverse side of this form, within 30 days of placement of the young
10. Verify and remit/reconcile any underpayments within 45 days of FFA
adult. The needs and services plan shall be updated at least every six
notification of such underpayments.
months.
11. Notify the FFA within 12 months of suspected overpayments, in
8.
Written progress reports shall be provided at least every six months or
accordance with applicable laws and regulations.
more frequently by mutual agreement.
12. Provide arrangements for educational travel to the young adult’s
9.
Give placing agency 7-day notice of intent to discharge or move
secondary school of origin as appropriate.
this young adult. Notify the placing agency of any intended move of
13. Provide a contact telephone number for emergencies and after
this young adult between certified homes prior to the move. The FFA
business hours:
has the authority to move a young adult in the case of imminent risk to
Emergency #:(
)
the young adult or family. The FFA shall notify the placing agency within
24 hours of such move.
10. Provider social worker shall visit this young adult in private in their foster
home at least once per calendar month and provide documentation of
these visits to the placing agency caseworker/probation officer on a
flow basis every month as visits are completed.
11. Provide state and federal agencies access to records as provided by
state and federal law.
12. Follow any requirements associated with the county’s clothing
allowance policy and procedures.
13. 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. Inform county upon discovery of any apparent overpayment.
15. Immediately notify the placing agency of any changes to the young
adult’s arrangement for educational travel to the secondary school of
origin, as appropriate.
SOC 153 (1/12) REQUIRED FORM -- NO SUBSTITUTE PERMITTED
PAGE 1 OF 2
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