Attachment #4

AGREEMENT REGARDING APPLICATION TO DBHDD SPECIAL CONTRACTED SERVICES FOR PARENT/LEGAL GUARDIAN

This agreement concerns the application for DBHDD Special Contracted Services (Child & Adolescent, Room Board and Watchful Oversight / Intensive Community Support Program) on behalf of

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Name of Child

As the parent or legal guardian of the child named above, I understand an application for Room, Board and Watchful Oversight (residential placement) or Intensive Community Support Program (ICSP) has been made on behalf of my child to the DBHDD. I understand that DBHDD provides authorization for funding youth who are residents of Georgia, and that should I move out of state, my child will no longer be eligible for funding. I agree to fulfill the following responsibilities during the application, admission, wraparound services delivery and placement process:

While in placement, pay for all personal expenses for my child not covered by the DHS payment rate. Such personal expenses include, but are not limited to: clothing, personal allowances, hair care, cosmetics, birthday and holiday gifts, medical expenses not covered by Medicaid or private insurance, outside activities and recreation, and transportation home or to other outside activities.

Contribute toward the cost of the placement or ICSP in the amount of $______per month. Payment is made on a monthly basis directly to the provider agency, according to arrangements made between the parent and the provider agency. Contributions will continue as long as the child is in placement or receiving ICSP services. If the parent is able to increase the amount of contribution, the case manager will forward notification to DBHDD. If the child has SSI, Child Support, Adoption Supplement, or other income, fifty percent (50%) of the monthly amount will be contributed to the cost of the residential placement and twenty-five percent (25%) of the monthly amount will be contributed for ICSP services. If the child has no income, the contribution for services will be determined based upon the parent/legal custodian’s income.

Participate in the supports provided to prepare for my child’s return home from residential placement and assist in the development of a discharge plan and after care plan upon admission of my child to a RBWO placement. Understand that RBWO placement does not exceed 120 days, therefore I will allow my child to return home or to a placement that I will arrange for him/her. Participate in wraparound service delivery by allowing the ICSP provider access to my child in the home, school and community. Support services include but are not limited to: parent training and consultation, behavior management techniques, and therapeutic interventions that are appropriate. Maintain consistent and regular contact with my child with frequent visits to the placement, home visits, telephone contacts, and other correspondence. Participate in service delivery planning beginning at admission. Maintain consistent contact with the Provider agency to ensure mutual agreement and cooperation regarding the care and services provided to my child. Provide agency staff with information, recommendations, and cooperation regarding the care of my child.

.Agree to allow DBHDD and the Provider agency to have access to and share information relating to the medical, behavior management, treatment, placement and support needs of my child.

Maintain contact with the local case manager and inform him/her of any changes which may affect my child’s placement, treatment, and/or financial contributions.

Participate in responding to the gathering of outcome data regarding the care provided to my child by fully cooperating with DBHDD and provider agencies in the sharing of information related to my child’s circumstances and life situation at regular intervals during and following discharge from DHS funded services. Participate in and allow my child to participate in consumer satisfaction surveys.

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Signature of Parent/Legal Guardian Date

02/12