DEPARTMENT OF FAMILY AND CHILDREN’S SERVICES
VOLUNTARY FAMILY REUNIFICATION
Pursuant to Welfare and Institutions Code Section 16507.4
DFCS #:CHILD: / DOB: / CHILD / DOB:
CHILD: / DOB:: / CHILD / DOB:
CHILD: / DOB:: / CHILD / DOB:
PARENT(s):
ADDRESS:
TELEPHONE:
I understand that the Department of Family and Children’s Services has conducted an investigation and concluded that the child or children listed above, or sibling(s)/half sibling(s) of the child or children listed above, are in potential danger of abuse, neglect or exploitation within the meaning of California law. I am willing to accept services and participate in services designed to improve the situation described below. I understand that these services are a short term intervention and shall be limited to six months but may be extended if appropriate. The beginning and ending date for services will be noted in the Child Welfare Case Plan and I will receive a copy. Along with this Voluntary Family Reunification agreement, I have also signed a Voluntary Placement Agreement. I understand these agreements are subject to review by the Department.
SPECIFIC REASON(S) FOR INTERVENTION (Provide a Description of the presenting problem and the Family’s Needs)TERMS OF THE VOLUNTARY SUPERVISION AGREEMENT
I Agree to:
1. Work with DFCS to create a safe home environment for my/our child/children.
2. Cooperate with the assigned social worker and notify the social worker immediately if there are any
changes to my address or telephone number.
3. Refrain from the abuse of alcohol and the use or possession of illegal drugs.
4. Enroll in, actively participate in, and complete the following service programs:
Parent Education; Drug and Alcohol Assessment; Drug and Alcohol Counseling;
Twelve-Step Program; Domestic Violence Assessment; Domestic Violence Counseling;
Counseling; Other Program(s):
5. Complete the Parent Orientation classes:
6. Cooperate with the following additional services:
Drug Testing Home Supervision Paternity Testing
Other Service: / , as arranged by Social Worker.______
Signature of Parent or Guardian Dated
Signature of Parent or Guardian Dated
Signature of Social Worker Dated
(Social Worker is to provide a copy of this Voluntary Family Reunification Agreement to the parent/guardian as soon as practical.)
SSA Vol. Fam. Reun. Form..doc