passport to placement aero success we strive for excellence

Passport to Placement

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uccess

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trive for Excellence

Fulton County Department of Family and Children Services

Placement Passport

Child’s Name:___________

Placement: ____________ ____________ ____________

CONFIDENTIAL INFORMATION **This Placement Passport is to be kept by you as long as this child is in your care. Remember……When this child leaves your care, this Passport travels with the Child.


PLACEMENT PASSPORT TABLE OF CONTENTS

● PHOTO OF CHILD● ALL ABOUT ME!● MY PERSONAL DIRECTORY●PLACEMENT PASSPORT CHECKLIST● PLACEMENT PRESENTATION FORM● INITIAL CUSTODY FORM● COURT ORDER● FOSTER CHILD INFORMATION SHEET (469)● PASSPORT AGREEMENT FOR PLACEMENT● CLOTHING ALLOWANCE (Form 58)● SCHOOL ENROLLMENT FORM● CONSENT FOR MEDICAL AND DENTAL FORM● PHYSICAL EXAMNATION/DENTAL (IF APPLICABLE)● CPA/CCI PASSPORT PLACEMENT AGREEMENT● AGREEMENT SUPPLEMENT (FORM 40, DFCS ONLY)● DAYCARE FORM (FORM 57/1027)● PASSPORT FOR WOMEN, INFANT AND CHILDREN● GRADY ASSESSMENT/ PSYCHOLOGICAL (AGENCY USE ONLY)● PERSONAL PROPERTY INVENTORY (Entering Home)● PERSONAL PROPERTY INVENTORY (Exiting Home)

●

This Passport Belongs To:

PLACEMENT PASSPORT


Name: Nickname:

Date of Birth:

***This Placement Passport is to be kept by you as long as this child is in your care. Remember….when this child leaves your care, this Passport travels with the child.

4-PlyProviderFoster ParentResource CenterFoster Care Unit

Fulton County Department of Family and Children ServicesALL ABOUT ME!

Name: DOB:

Nickname: AGE:

School: Grade:

Weight: Height:

Hair Color: Eye Color:

Clothing Size: Shoe Size:

Favorite Color: Favorite Activity:

Things I Like to do:

What are my fears:

Places I like to go: Favorite Animals:4-PlyProviderFoster ParentResource CenterFoster Care Unit

Things I dislike doing:


Important Person’s Name:

Relationship

Address Phone Number &

E-mail

My Personal Directory

Important People in My Life

***This Placement Passport is to be kept by you as long as this child is in your care. Remember...

when this child leaves your care, this Passport travels with the child.


Fulton County Department of Family and Children Services PLACEMENT PASSPORT CHECKLIST

NEW TO CARE □ DISRUPTION □ PLAN MOVE □ RESPITE □

Child NAME: ______________________________________ DOB: _______________ AGE: ______ GENDER:___________ PARTNERSHIPPARENT/CPA/CCI __________________________________________ DATE PLACED: __________________________

DATE RECEIVED DATE EXPECTEDBIRTH CERTIFICATE ( ) _______________ ______________

COURT ORDER ( ) _______________ ______________

SOCIAL SECURITY CARD (IF APPLICABLE) ( ) _______________ ______________

INITIAL CONTACT FORM ( ) _______________ ______________

EYE, EAR, DENTAL FORM ( ) _______________ ______________

CONSENT FOR MEDICAL OR DENTAL/MEDICAID CARD ( ) _______________ ______________

PHYSICAL EXAMINATION/DENTAL (If applicable) ( ) _______________ ______________

HOSPITAL DISCHARGE FORM (FAX TO HOSPITAL) ( ) _______________ ______________

DAY CARE FORM (FORM 57/1027) ( ) _______________ ______________

FOSTER CHILD INFORMATIN SHEET (FORM 469) ( ) _______________ ______________

AGREEMENT SUPPLEMENT (FORM 40) (DFCS ONLY) ( ) _______________ ______________

INSTITUTIONAL AGREEMENT (PRIVATE AGENCY/GROUP HOME) ( ) _______________ ______________

AGENCY APPLICATION (IF APPLICABLE) ( ) _______________ ______________

WIC ( ) _______________ ______________

CLOTHING (FORM 48) ( ) _________________ _____________

SCHOOL ENROLLMENT ( ) _______________ ______________

GRADY ASSESSMENT / PSYCHOLOGICAL (Agency use only) ( ) _______________ ______________

*******************************************************************************************************************************************************************

PRO CASE MANAGER SIGNATURE: _________________________________________ DATE: ____________ TIME: _________________

PLACEMENT ASSISTANT SIGNATURE: ______________________________________ DATE: ____________ TIME: _________________

SUPERVISOR SIGNATURE: ________________________________________________ DATE: ____________ TIME: _________________

PARTNERSHIP PARENT/CPA SIGNATURE: __________________________________ DATE: ____________ TIME: _________________


Fulton County Department of Family and Children ServicesPLACEMENT PRESENTATION FORM

DATE: ___________________

CHILD’S NAME____________D.O.B:_____________AGE:______GENDER:_______

CASE NUMBER (if applicable): _________________________________________________________________________________________________________________

*Circumstances that brought child into Agency custody: _________________________

Family Resource Center Placement Assistance Unit (404) 762-4000 for School Records

Placement Assistance assigned to: ___________________Mobile:________________ (Name)Child’s Case Manager:_______________Office:______________Mobile: ___________CM Supervisor:_____________________Office:______________Mobile:___________Administrator:______________________Office:______________Mobile:___________

Fulton County 24-Hour Hotline (404-699-4399)(For all after hour’s emergencies regarding children in placement)

*****************************************************************************************************The initial FTM and Family Visitation will occur the same day as the Court hearings, Resource/Provider are expected to bring Child/Children to all pending Court Hearings.Name of School: __________________Addres____________________Grade:______ (Address) (City) (Zip)

Daycare/After School Program/Camp: ______________________________________ (Name / Address / Phone)*Known Medical Conditions/Concerns:____________________________________________________________________________________________________________

*Does this child have medication with Him/Her now? □ YES□NO

*Type of Placement □ DFCS □ CPA □ CCI Agency Name: _______________ Placement Name: ______________________________________________________

Address: _____________________________________________________________ (Address) (City) (Zip)

Phone/Contact Number's): _______________________________________________

PLACEMENT RESOURCE SUPERVISOR OR DESIGNEE: ____________________



INITIAL CUSTODY FORM

Date: ______________________

To: ________________________

In the Interest of:

Child: ___________________________ DOB: _________________

Child: ___________________________ DOB: _________________

Child: _ ____________ DOB: _________________Child DOB: _________________

By order of the Fulton County Juvenile Court the above named child (ren) are in the custody of Fulton County Department of Family and Children services.The above named child (ren) has (have) been placed in foster care by order of the Fulton County Juvenile Court and placed in a foster home for care.The Probable Cause (72 hour hearing)/FTM is scheduled for ________________________, after which a Family. (Date, Time, and Location)Team Meeting (FTM) will be held with all concerned parties invited. You may invite anyone that you feel has a vested interest in your family (i.e. relatives, teachers, neighbors, pastor etc.). We would like to strongly encourage you to attend these proceedings.If you have any questions or need any assistance, you may contact the following.

_________________, CPS Case Manager: Office: ______________ Cell: __________

_________________, CPS Supervisor: Office: _________________ Cell: __________

_________________, CPS Administrator: Office: _______________ Cell:___________

_________________, PLC Case Manager Office: _______________Cell: __________

_________________, PLC Supervisor Office: __________________Cell: _______ _________________,PLC Administrator: Office: ________________ Cell: ___________4-Ply

ProviderFoster ParentResource CenterFoster Care Unit


FOSTER CHILD INFORMATION SHEET

Child’s Name: _______________DOB: ______________ Age:________

Name Child likes to be called: __________________________

Medical history (disorders, allergies, dental history): ___________________________

Psychological and Social History: _________________________________________

School History (Last school attended, achievement level, school adjustment): ____________________________________________________________________________________

Why is child in foster care? ____________________________________________________________________________________

History of foster care (other families: where (city or part of town), and why child was moved): ____________________________________________________________________________________

Does child have special toy or object? Yes No Is it in his/her possession now? Yes No

Sleep patterns and rituals: _______________ Food preferences and dislikes: _____________________

Are pictures of natural family available? Yes No Does child have them with him/her now? Yes NoWhere is Paternal Family? _____________________________________________________________________________________Who are the members? _____________________________________________________________________________________Where is Maternal Family _____________________________________________________________________________________Who are the members? _____________________________________________________________________________________

Are siblings in foster care? Yes No Where? ________________________________________________

What are the plans for this child? __________________________________________________________

What are the Child’s current and past behaviors? ________________________________________________________________

Why is the Child coming from one placement to another? ___________________________________________________________

What is the Disruption? _____________________________________________________________________________________

Who is the assigned Doctor? ___________________________________ What is the Therapist Name? ______________________

Who does the Child receive counseling from? ___________________________________________________________________

Religious preferences (if any): _________________________________

Clothing preferences (colors and styles): ____________________________________________________

Favorite Foods? _______________________ Foods Child is allergic too (how long) _________________

Is child allergic to dairy products? ____Yes _____No

What is child’s bedtime? _______________ What clothing does child like to sleep in? _______________

Does child like to have a bedtime story read to him/her? Yes No If so Favorite book: ________________

Information provided by: _________________________ Date assigned to Casemanager: _____________


Fulton County Department of Family and Children Service

PASSPORT AGREEMENT FOR PLACEMENT WITH PARTNERSHIP PARENTS

NEW TO CARE □ DISRUPTION □ PLAN MOVE □ RESPITE □

PARTNERSHIP PARENT: _______________________ DATE PLACED: ____________

CHILD NAME: ___________________ DOB: __________ AGE: ______ GENDER: ____

CHILD NAME: ___________________ DOB: __________ AGE: ______GENDER: ____

CHILD NAME: ___________________ DOB: __________ AGE: ______GENDER: ____

CHILD NAME: ___________________ DOB: __________AGE: _______ GENDER: ___

CHILD NAME: ___________________ DOB: _________ AGE: _______ GENDER: ____

______________________, partnership parent with Fulton County(PARTNERSHIP PARENT NAME)

Department of Family and Children Services have agreed to accept the child/children listed above into his/her home for placement.

PARTNERSHIP PARENT SIGNATURE: __________________ DATE: ____________

PRO CM: ___________________________________________ DATE: ____________

PRO SUPERVISOR: _________________________________ DATE: ____________

________________________________________________________________________

If you are in need of immediate assistant within the next 48 hours, please contact:

CPS/PLC CM: ______________________OFFICE: ____________MOBILE:__________

CPS/PLC SUPERVISOR: _____________OFFICE:_____________MOBILE:_________

ADMINISTRATOR: ___________________OFFICE:_____________MOBILE:_________



Clothing Allowance

TO: __________________________________

FROM: __________________________________

RE: __________________________________

DATE: __________________________________

Dear ____________________________

I hereby authorize _____________________________________________to (Partnership Parent/CPA/CCI)purchase the following articles of clothing:

For _______________________DOB: ____________Age: ____ Sex: ______ (Child’s Name)

not to exceed the sum of $______________.

(Amount)Signed: ___________________________ Date: ________________

Supervisor’s Approval: ______________ Date: _________________ (Supervisor’s Signature)

CPS/PLC CM: ________________________Office: _____________Mobile: __________

CPS/PLC Supervisor: __________________Office: _____________Mobile: __________

Administrator: ________________________Office: _____________Mobile: __________

Form 584-PlyProviderFoster ParentResource CenterFoster Care Unit


SCHOOL ENROLLMENT FORM

DATE: ________________________________________

TO: ___________________________________________

FROM: FULTON COUNTY FAMILY RESOURCE CENTER

CHILD NAME: _________________ DOB: ______________ AGE: _____________

CHILD NAME: _________________ DOB: ______________ AGE: _____________

CHILD NAME: _________________ DOB: ______________AGE: ______________

CHILD NAME: _________________ DOB: ______________ AGE: ___________

The child/children listed above are in the legal custody of Fulton County Department of Family and Children Services. The child/children are currently placed in the home/Agency of: __________________________ (Agency Name Only)

________________________________________________________(PARTNERSHIP PARENT/CPA/CCI)

________________________________________________________ ADDRESS CITY ZIP

________________________________________________________PHONE NUMBER

_________________________________ is authorized to enroll the above named child/children in school. If you have additional questions, please contact me at the telephone number listed below.

CPS/PLC CM: __________________ OFFICE: _____________MOBILE:_________

CPS/PLC SUPERVISOR: _________ OFFICE: _____________MOBILE:_________

ADMINISTRATOR: ______________ OFFICE: _____________MOBILE:_________

***************************************************************************************************OFFICE LOCATION: FULTON COUNTY FAMILY RESOURCE CENTER (404) 762-4000

If you are in need of immediate assistant within the next 48 hours, please contact:PRO CM: _______________________OFFICE: _____________MOBILE: _______

PRO SUPERVISOR: ______________OFFICE: _____________MOBILE: ________



CONSENT FOR MEDICAL AND DENTAL CARE OF A FOSTER CHILD

CHILD’S NAME: __________________DATE OF BIRTH: _____________

MEDICAID NUMBER: ________________________

__________________________________County Department of Family (County)

and Children Services having legal custody of ______________________________________________________ does (CHILD’S NAME)

hereby give consent to _______________________________________ (PARTNERSHIP PARENT/ CPA/CCI)

and such agents of_________________________________________ with

whom the child may be placed in____________________ (PARTNERSHIP PARENT/ CPA/CCI)

Foster Care to authorize routine medical and dental care. All copies of medical records will be forwarded to assigned Case Manager.

Any request to authorize emergency medical treatment, such as emergency surgery, general anesthesia and blood transfusions, if necessary, shall be forwarded to the assigned Case Manager, Supervisor, Administrator or Program Director for prior approval.

________________________________________ Signature of Authorizing RepresentativeFulton County Department of Family and Children Services

_____________________________ Date



CPA/CCI PASSPORT PLACEMENT AGREEMENT

CHILD’S NAME: _______________ DOB: ___________ AGE: ____ GENDER: _____

CHILD’S SOCIAL SECURITY NUMBER__________SHINES CASE NUMBER: ______

CHILD’S MEDICAID NUMBER: _________________ DATE PLACED: _____________

NAME OF CPA/CCI:_________________________________________________ ADDRESS OF CPA/CCI: __________________________________________________

CITY__________________________ STATE: _____________ COUNTY: ___________

CONTACT PERSON: __________________TELEPHONE NUMBER: _____________

EMAIL ADDRESS: ______________________________________________________

This is an agreement between____________________________________ (NAME OF CPA/CCI AGENCY)and Fulton County Department of Family and Children

Service.______________________________________________________

(NAME OF CPA/CCI AGENCY)

agrees to provide care for _______________________________________.

(NAME OF CHILD)

The child’s per diem rate is currently $ ___________ per day.

RBWO CATEGORY:______________________

*************************************************************************************

If you have any questions, as it relates to this agreed, please contact the PRO CM or PRO Supervisor at the telephone numbers listed below.

PRO SUPERVISOR: _____________________TELEPHONE NUMBER: ___________

CPA/CCI CM: __________________________ TELEPHONE NUMBER: ___________

CPA/CCI SUPERVISOR: _________________TELEPHONE NUMBER: ___________

3-PlyProviderResource CenterFoster Care Unit

For contractual issues contact your Regional Supervisor

Opum Main (404)657-3572

3-PlyProviderResource CenterFoster Care Unit

OFFICE LOCATION: FULTON COUNTY FAMILY RESOURCE CENTER (404) 762-4000

Fulton County Department of Family and Children ServicesAGREEMENT SUPPLEMENT

(DFCS Foster Parent) _________________County Department of Family and Children ServicesCase Number: _____________________

(Foster Home)

I have this date (Received into) my home (Released from)__________________________DOB: _____________CASE # ____________

__________________________DOB: _____________CASE # ____________

__________________________DOB: _____________CASE # ____________

__________________________DOB: _____________CASE # ____________

__________________________DOB: _____________CASE # ____________

__________________________DOB: _____________CASE # ____________

From/To: ______________________________, ____________________County (NAME OF PERSON)

Department of Family and Children Services for/from foster care in accordance

with the agreement with the ____________________County Department of

Family and Children Services to provide Foster Care.

Signed: ______________________________

(Foster Father)

______________________________

(Foster Mother)

Date: ______________________ ______________________________ Representative of the _____________County Department of Family and Children ServicesForm 40

3-PlyFoster ParentResource CenterFoster Care Unit


PASSPORT FOR WOMEN, INFANT, AND CHILDREN SERVICES

TO: _______________________ COUNTY HEALTH DEPARTMENT

Name of Health Dept: _____________________Address: _______________Phone: ________

FROM: FULTON COUNTY FAMILY RESOURCE CENTER _________________________________________ (PRO CM NAME/TELEPHONE NUMBER)

DATE: _______________________

REASON: ____________________

CHILD NAME: _________________________DOB: __________ AGE: ______ GENDER: ____

CHILD NAME: _________________________ DOB: ___________AGE: ______ GENDER: ____

CHILD NAME: __________________________DOB: __________ AGE: _______GENDER: __

The child/children listed above are in the legal custody of Fulton County Department of Family and Children Services. The child/children are currently placed in the home of:

________________________________________(Partnership Parent/CPA/CCI)

________________________________________ Address City Zip

________________________________________(Phone Number)

________________________________ is responsible for the daily care of the child/children listed (PARTNERSHIP PARENT/ CPA/CCI NAME)

above Fulton County Family Resource Center is giving permission for _______________________ (PARTNERSHIP PARENT/ CPA/CCI NAME)

to receive WOMEN, INFANT, AND CHILDREN vouchers for the child/children listed above. If you are in need of immediate assistant within the next 48 hours, please contact:

CPS/PLC CM: ______________________ OFFICE: ________________MOBILE:____________

CPS/PLC SUPERVISOR: _____________ OFFICE: ________________MOBILE:____________

ADMINISTRATOR:___________________OFFICE:_________________MOBILE: ____________


Fulton County Department of Family and Children ServicesPersonal Property Inventory (Entering Home)

Child’s Name: Date:

Item Description Quantity Comments



Personal Property Inventory (Exiting Home)

Child’s Name: Date:

Item Description Quantity Comments


passport to placement aero success we strive for excellence

Documents

day care form form

daycare form form

passport agreement

passport travels

homethis passport

respite child

initial contact form

school enrollment form