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Forms & Policies

Important Forms & Policies

Forms

15-313 Caregivers Report to the Court
07-090 Caregiver Monthly Mileage
18-400 Foster Parent Reimbursement Claim and Checklist
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
09-052 Affidavit of Forged Endorsement
09-653 Background Authorization
10-261 Foster Care Rate Assessment
10-290 Policy Agreement (Children's Administration)
16-231 Permanency Planning Supports and Resources Matrix

Placement Packet

Below are the required forms when a child is placed in out of home care.

Cover letter and description of documents below

Caregivers and Relatives

15-300 Child Information and Placement Referral

Required to be given to all caregivers and signed by the caregiver. Provides specific information about the child to assist you in safely caring for the child and meeting their needs. Contains information on: siblings, contact information, reason for placement, visit plan, medical info, health concerns, medications, emotional/behavioral concerns. Only limited information may be known about a child at the time of initial placement.CA will provide updated information as it becomes available. This completed form must be printed twice so both the caregiver and worker have signed copies.

15-281 Placement Agreement

Provides necessary and important information for caregivers to ensure the safety and well being of the child placed in your home by CA. It establishes the agreement between CA and the Caregivers and will assist you in understanding your role in helping meet the needs of the child, working with CA, the assigned social worker and the Court.

10-455 Medical Log

Caregivers record medical/dental appointments, medications, etc.

10-454 Caregiver Authorization

Provides verification of the child's placement in your home, and allows the caregiver to engage in specific medical/dental, treatment, education, decisions for the child and identifies information about out of state travel requirements.

13-708 Voucher for Interim Pharmacy and Medical Services for Foster Children

Document to use for medical services, if you have not received the child's ProviderOne Medical card. Authorizes medical/dental/pharmacy services and is to be provided to each provider for when service is received.

09-653 Background Authorization

Required form to be completed by each person, age 16 and older residing in your home or on your property with potential access to the child. This form is also utilized for any person you will use in your home to provide respite care for the child. It is very helpful to have your respite providers complete the background check form as early as possible.

13-843 Foster Care Initial Health Screen

Form to be completed by Dr. for the child's first scheduled medical appointment. This appointment is called the Initial Health Screen and is required within five (5) days of placement. Please obtain copies of the form once completed by the doctor for the assigned CA worker and for your records.

22-1445 Initial Health Screen Fact Sheet

Offers guidance to caregivers on their important role in obtaining the Initial Health Screening within 5 days when a child is first placed into out-of-home care.

22-019 How to get a well-child checkup - EPSDT Pamphlet

Early Periodic Screening, Diagnosis and Treatment (EPSDT) this is a required free health program for children in foster care. This appointment can be combined with the Initial Health Check appointment. EPSDT must be completed within 30 days of placement.

Child Health & Education Tracking (CHET) Flyer

A screening and assessment program for children. The CHET screener from CA will contact you for an appointment and will come to your home. This flyer shares information on assigned worker responsibilities and caregiver's role. You will receive a written copy of this report once completed.

Family Team Decision-Making Meetings (FTDM) Flyer

Information about these important meetings; CA values your information and wants you to attend if possible! FTDMs are held when a decision needs to be made about where a child should live, addresses safety concerns and develops a plan for the child.

Caregiver's Report to Court - Effective Communication

Report form used by caregivers to share their valuable information with the court for scheduled court hearings; helps focus and share your first-hand information to help the court make important decisions for the child.

15-313 Caregivers Report to the Court

FamLink sends a prompt to the social worker 30 days before the child's court hearing to send a notice to the foster parents about the upcoming court hearing. This also helps remind foster parents to submit the Caregivers Report to the Court. This report form is used by caregivers to share their valuable first hand information with the court for scheduled court hearings when important decisions are made for the child.

07-090 Caregiver Monthly Mileage

Child specific mileage can be reimbursed for caregivers. This form helps you know what travel can be reimbursed and guides you through submitting the completed form to your assigned CA worker.

22-066 Tips for Caregivers Flyer

Offers quick information about the required monthly social worker visit to your home to meet with the child and you. Questions the worker may ask you and suggested questions for you to ask the worker.

22-1455 Keeping Brothers and Sisters Connected

Important information on the importance of brothers and sisters and helping them maintain connections if they have been separated. Separated siblings must visit twice per month per policy.

HCA 22-1217 Foster Parents Guide To Medicaid

Helpful information for caregivers when using Medicaid services. Remember to take the child to a doctor or medical provider that takes the ProviderOne Services Card.

27-093 School Notification

The School Notification Form is a tool for social workers to inform schools when a child or youth has been:

  • Newly placed in foster care
  • Changed placement, or
  • Returned home

The form provides details to schools "at a glance" that is essential for them to know about children and youth placed with CA.

Relatives Only

15-280 Unlicensed Caregiver Placement Checklist

Lists requirements the assigned worker must complete within 72 hours of placing the child in your home. Contains your emergency contact information. Lists basic safety household items the worker must identify. Please assist the worker in completing these requirements - Please share your e-mail address with the worker.

10-453 Household Safety Inspection for Unlicensed Relatives/Suitable Others

The form ensures specific health and safety factors in your home are addressed by the social worker before placement.

14-001 Application for Benefits

You may file this application with your local Community Services Office to assist you in receiving financial support for the child in your care. This application is based on the child's need and does not consider your income while the child has an open case with CA.

Relative and Other Suitable Person Support Services Funds

Information about funds that can be authorized for relatives or suitable persons to help support placement of a child with their relatives.

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