Placement/Address Change Form

/ Santa ClaraCounty
Social Services Agency
Department of Family and Children’s Services

PLACEMENT/ADDRESS CHANGE FORM

C. TEMPORARY CUSTODY INCLUDING FAILED FM

(Means that a new legal authority for placement will start; new placement episode)

New or dependent child taken into temporary custody

New or dependent child taken into temporary custody and placed in out-of-home care

CASE INFORMATION
CASE NAME: / DFCS CASE NUMBER:

For siblings with the same information, list oldest child first and then younger siblings by age

Name: / SS# / Gender / DOB / Attorney Name
Child 1 : / FemaleMaleUnknown
Placement Change Reason:Select OneChild in Medical/Psychiatric FacilityChild moved to be placed in Fost/Adoptive PlacemenChild Ran Away From PlacementChild's BehaviorComplaint on Foster HomeFoster Home/Agency RequestHigher Level of Care RequiredIncarceratedIncoming ICPCIntercounty Transfer *Lower Level of Care RequiredMinor Mother Needs to be Placed w/ Child - WFFH**Moved from Emergency ShelterPlaced with GuardianPlaced with RelativeReturned from Runaway StatusSCP moved to new address (and did not take child)SCP moved to new address (with the child)SILP PlacementTHP Plus FCOther - Explain ***
Dual Status (DFCS/SARC) Child? N/ANoYes / Dual Status Rate: 898.002006.00 / Effective Date:
Child 2 : / FemaleMaleUnknown
Placement Change Reason: Select OneChild in Medical/Psychiatric FacilityChild moved to be placed in Fost/Adoptive PlacemenChild Ran Away From PlacementChild's BehaviorComplaint on Foster HomeFoster Home/Agency RequestHigher Level of Care RequiredIncarceratedIncoming ICPCIntercounty Transfer *Lower Level of Care RequiredMinor Mother Needs to be Placed w/ Child - WFFH**Moved from Emergency ShelterPlaced with GuardianPlaced with RelativeReturned from Runaway StatusSCP moved to new address (and did not take child)SCP moved to new address (with the child)SILP PlacementTHP Plus FCOther - Explain ***
Dual Status (DFCS/SARC) Child? N/ANoYes / Dual Status Rate: 898.002006.00 / Effective Date:
Child 3 : / FemaleMaleUnknown
Placement Change Reason: Select OneChild in Medical/Psychiatric FacilityChild moved to be placed in Fost/Adoptive PlacemenChild Ran Away From PlacementChild's BehaviorComplaint on Foster HomeFoster Home/Agency RequestHigher Level of Care RequiredIncarceratedIncoming ICPCIntercounty Transfer *Lower Level of Care RequiredMinor Mother Needs to be Placed w/ Child - WFFH**Moved from Emergency ShelterPlaced with GuardianPlaced with RelativeReturned from Runaway StatusSCP moved to new address (and did not take child)SCP moved to new address (with the child)SILP PlacementTHP Plus FCOther - Explain ***
Dual Status (DFCS/SARC) Child? N/ANoYes / Dual Status Rate: 898.002006.00 / Effective Date:
Child 4 : / FemaleMaleUnknown
Placement Change Reason: Select OneChild in Medical/Psychiatric FacilityChild moved to be placed in Fost/Adoptive PlacemenChild Ran Away From PlacementChild's BehaviorComplaint on Foster HomeFoster Home/Agency RequestHigher Level of Care RequiredIncarceratedIncoming ICPCIntercounty Transfer *Lower Level of Care RequiredMinor Mother Needs to be Placed w/ Child - WFFH**Moved from Emergency ShelterPlaced with GuardianPlaced with RelativeReturned from Runaway StatusSCP moved to new address (and did not take child)SCP moved to new address (with the child)SILP PlacementTHP Plus FCOther - Explain ***
Dual Status (DFCS/SARC) Child? N/ANoYes / Dual Status Rate: 898.002006.00 / Effective Date:
Child 5 : / FemaleMaleUnknown
Placement Change Reason: Select OneChild in Medical/Psychiatric FacilityChild moved to be placed in Fost/Adoptive PlacemenChild Ran Away From PlacementChild's BehaviorComplaint on Foster HomeFoster Home/Agency RequestHigher Level of Care RequiredIncarceratedIncoming ICPCIntercounty Transfer *Lower Level of Care RequiredMinor Mother Needs to be Placed w/ Child - WFFH**Moved from Emergency ShelterPlaced with GuardianPlaced with RelativeReturned from Runaway StatusSCP moved to new address (and did not take child)SCP moved to new address (with the child)SILP PlacementTHP Plus FCOther - Explain ***
Dual Status (DFCS/SARC) Child? N/ANoYes / Dual Status Rate: 898.002006.00 / Effective Date:

* If: Inter-County Transfer (Moved to/from another County with Jurisdiction)

Transfer Date: CountyName:

** If: Minor Mother needs to be placed with Child - WFFHS-NON WFFH Non-Dep Inft No SRPS-WFFH Non-Dep Inft No SRPS-WFFH Non-Dep Inft With SRPS-Dep Minor Parent With Dep Inft 4AS-Dep Minor Parent With Dep Infant 4BS-Dep Minor Parent With Dep Infant 4C

*** If: Other (Explain):

SOCIAL WORK AUTHORIZATION

Date:

Primary SW Name: / Worker#: / Phone#:
Secondary SW Name: / Worker#: / Phone#:
Authorized by (if different than SW):
NEW PLACEMENT INFORMATION
Is this an ESH or an Emergency Placement (309D)? / Select OneNoESHEmergency Placement (309D)
If this is a court case, do you have Court Orders for the new placement facility type?
(If not, submit the SCZA17 and then later update the PTT when orders obtained) / Select OneYesNo
If this is an address change AND child remains with the same caregiver, what was the address move date? (The date that the caregiver/agency moved with the child to a new address)
New Placement Date:
(1st day that the child arrived at this placement of it applicable, the date payment will begin)
New Placement Agreement Signed Date:
(Date that the caregiver signed the placement agreement provided by the social worker)
EDUCATION INFORMATION
Child 1: / Who Has Ed.Rights for this Child?
New School Name: / Ed. Rights: Date limited, if applicable:
Grade: / Start Date: / City or Zip:
Previous School Name:
Grade: / End Date: / City or Zip: / Reason Left:
Is the child receiving IEP or IFSP? Select OneNoIEPIFSP / Start Date: / IEP Type: Select One Initial IEPAnnual IEPTriennial IEPIEP Out of Date
Was the child checked out of their previous school? Select OneYesNo
Has the new school been notified of change of school? Select OneYesNo
Comments:
Child 2: / Who Has Ed.Rights for this Child?
New School Name: / Ed. Rights: Date limited, if applicable:
Grade: / Start Date: / City or Zip:
Previous School Name:
Grade: / End Date: / City or Zip: / Reason Left:
Is the child receiving IEP or IFSP? Select OneNoIEPIFSP / Start Date: / IEP Type: Select One Initial IEPAnnual IEPTriennial IEPIEP Out of Date
Was the child checked out of their previous school? Select OneYesNo
Has the new school been notified of change of school? Select OneYesNo
Comments:
Child 3: / Who Has Ed.Rights for this Child?
New School Name: / Ed. Rights: Date limited, if applicable:
Grade: / Start Date: / City or Zip:
Previous School Name:
Grade: / End Date: / City or Zip: / Reason Left:
Is the child receiving IEP or IFSP? Select OneNoIEPIFSP / Start Date: / IEP Type: Select One Initial IEPAnnual IEPTriennial IEPIEP Out of Date
Was the child checked out of their previous school? Select OneYesNo
Has the new school been notified of change of school? Select OneYesNo
Comments:
Child 4: / Who Has Ed.Rights for this Child?
New School Name: / Ed. Rights: Date limited, if applicable:
Grade: / Start Date: / City or Zip:
Previous School Name:
Grade: / End Date: / City or Zip: / Reason Left:
Is the child receiving IEP or IFSP? Select OneNoIEPIFSP / Start Date: / IEP Type: Select One Initial IEPAnnual IEPTriennial IEPIEP Out of Date
Was the child checked out of their previous school? Select OneYesNo
Has the new school been notified of change of school? Select OneYesNo
Comments:
Child 5: / Who Has Ed.Rights for this Child?
New School Name: / Ed. Rights: Date limited, if applicable:
Grade: / Start Date: / City or Zip:
Previous School Name:
Grade: / End Date: / City or Zip: / Reason Left:
Is the child receiving IEP or IFSP? Select OneNoIEPIFSP / Start Date: / IEP Type: Select One Initial IEPAnnual IEPTriennial IEPIEP Out of Date
Was the child checked out of their previous school? Select OneYesNo
Has the new school been notified of change of school? Select OneYesNo
Comments:
FACILITY TYPE: Select One Approved-HomesCA-Licensed-Facilities-(Family-Living)CA-Licensed-Facilities-(Group-Living)CA-Shelter/Receiving-HomeEFINon-Foster-Care-PlacementsOther-Non-Licensed-Facilities-or-Non-CA-LicensedOut-of-State-Facilites-(outside-CA-or-USA)RFA ApprovedRFA-TempSILP PlacementTHP THP +THP Plus FC

(Choose an option from drop-down menu and answer one corresponding section below)

1 / CA Shelter/Receiving Center
(Skip New Caregiver (SCP) and New Placement Payee Info.) / Select One Santa Clara County (Union Ave.)Another County
Other County Name (If Applicable):
2 / Approved Homes (approval packet needed)
(Questions call OPP Supervisors or EW) / Select One Relative Home in CALegal Guardian Home in CANREFM Home in CA
Approval Packet is attached to this request: Yes No
If no, indicate the reason the approval is not needed:
3 / CA Licensed Facilities (Family Living)
(Skip New Placement Payee Info.) / Select One Licensed County Foster HomeFFA Certified HomeSmall Family Home (licensed by the state)RFA Home
4 / CA Licensed Facilities (Group Living)
(Skip New Caregiver (SCP) and New Placement Payee Info.) / Select One Group Home/Community Care FacilityCTF (Community Treatment Facility)THP (18-25)THPP ( Licensed Trans. Housing Prog. Foster Child)
5 / Out of State Facilities (outside CA or USA) / Select One Relative Home outside CA or USANREFM Home outside CA or USALegal Guardian outside CA or USANon-Relative Home outside CA or USAICPC
Copy of License is attached to this request: Yes No
If no, explain:
6 / Non-Foster Care Placements
(Skip New Caregiver (SCP) and New Placement Payee Info.) / Select One Juvenile Hall/IncarcerationHospital (Medical/Psychiatric)JOB CoreOther
For Other, describe:
7 / THPP
8 / THP + (Transitional Housing Program Plus)
9 / EFY
10 / Other Non-Licensed Facilities or Non-CA Licensed Facilities / Select One Tribe Specific HomeCourt Specified Home
Tribe Name (if Applicable):
For Court Specified Home – Explain:
NEW CAREGIVER (SCP) INFORMATION
For Licensed Facilities in California, We Only Need Their Names.
For Other Home Types, We Need As Much Demographic Information As Possible.
Primary Caregiver Name: / Social Security # (Optional)
DOB: / Gender: / Ethnicity:
Language: Primary Other Language / Marital Status:
Secondary Caregiver Name: / Social Security # (Optional)
DOB: / Gender: / Ethnicity:
Language: Primary Other Language / Marital Status:
Caregiver Relationship: Select One Relative GuardianRelative Non-GuardianNon-Relative GuardianNon-Relative Non-Guardian / Name of Agency (if applicable):
New Placement Address: (Specific location of child’s placement):
City, State, Zip: / County:
Phone Number: / Other Phone Number:
NEW PLACEMENT PAYEE INFORMATION
Skip This Section For Foster Homes, Group Homes, and FFA Homes In California.
Payee Name: / Payable to the Primary Caregiver
Payable to the Secondary Caregiver
Payable to Both Caregivers
Other Payee Name:
DO NOT GENERATE SOC158 – Incoming ICPC CASE
Payee Mailing Address: / Same as placement address for child
Other Payee Mailing Address:

NEW PLACEMENT RATIONALE INFORMATION

Did you consider proximity to the school in which the child was enrolled at the time of placement? / Select One yesno
If child was not placed in proximity of school, why?
Select primary reason only / Select One No Homes Available in the School VicinityPlaced with a Relative or NREFMOther
For other reason, Explain:
Does this child have siblings who are also in placement? / Yes No
If yes, is this child placed with a sibling? / Yes No
If siblings are not placed together, why not?
Select primary reason only / Select One Child has special needs/behavioral problemsContact between sibings is dangerousInsufficient space in foster homePlacement together not in best interestCaretaker/SCP unwilling/unable to care for all sibCaretaker/SCP takes only certain gende/age/cultureSiblings interaction suspended by court odersiblings do not know each otherother reason (explain below)
For other reason, Explain:

TEMPORARY CUSTODY & REMOVAL INFORMATION

CHILD REMOVED FROM PARENT/LEGAL GUADIAN (New Protective/Temp Custody)

Primary Reason for Removal: (Mandatory, select only one): Care Taker Absence/IncapacityChild's Disability/HandicapEmotional AbuseExploitationGeneral NeglectPhysical AbuseRelinquishmentSevere NeglectSexual AbuseStatus OffenseSafely Surrendered Baby
Secondary Reason for Removal:(Optional, select all that apply)
Alcohol Abuse by Child
Care Taker Absence/ Incapacity
Child born w/Drugs in System
Child’s Disability or Handicap
Child Born w/Fetal Alcohol Syndrome
Parent Skill Hindered by Alcohol Abuse
Parent Skill Hindered by Drug Abuse
Child’s Behavior Problem / Parent Absent-Abandonment
Parent Absent-Death
Parent Absent-Incarceration
Drug Abuse by Child
Emotional Abuse
Exploitation
Homeless
Unhealthy/Unsafe Home / Status Offense
Physical Abuse
Sexual Abuse
Sexual Neglect
General Neglect
Severe Neglect
Relinquishment
Law Violation
Removed From
1st Caregiver Removed from (specific name):
Relationship to Child:
2nd Caregiver Removed from (specific name):
Relationship to Child:
Removed By: Law Enforcement DFCS Staff Surrendered Baby
Police Name:
DFCS Staff Name: / Police Badge #:
DFCS Staff worker #: / Police Phone #:
Staff Phone #:

Legal Notification of Parties of Temporary Custody Arrangements:

Mother Notified: / Date: / Time: / Notified of Rights
Father Notified: / Date: / Time: / Notified of Rights
Guardian Notified: / Date: / Time: / Notified of Rights
Attorney Notified: / Date: / Time: / Notified of Rights
Child Notified / Date: / Time: / Notified of Rights

COUNTY OF SANTA CLARA

SOCIAL SERVICES AGENCYSUMMARY PAGE

FAX to LACY @ 408-288-8850

C. TEMPORARY CUSTODY INCLUDING FAILED FM

PREVIOUS PLACEMENT INFORMATION: CHILD WAS REMOVED FROM PARENT/GUARDIAN

Removed From: / : / :
CHILD’S NAME / Dual Status DFCS/SARC / GENDER / BIRTHDATE / ATTORNEY NAME
N/A
N/A
N/A
N/A
N/A
DFCS CASE NAME: / DFCS Case No.

Education Provider:

Child: / Grade: / Start Date: / Ed Rights: limit:
New School: / Previous School: / IEP/IFSP: Select One
Child checked out of previous school? Select One / New School Been Notified? Select One
Child: / Grade: / Start Date: / Ed Rights: limit:
New School: / Previous School: / IEP/IFSP: Select One
Child checked out of previous school? Select One / New School Been Notified? Select One
Child: / Grade: / Start Date: / Ed Rights: limit:
New School: / Previous School: / IEP/IFSP: Select One
Child checked out of previous school? Select One / New School Been Notified? Select One
Child: / Grade: / Start Date: / Ed Rights: limit:
New School: / Previous School: / IEP/IFSP: Select One
Child checked out of previous school? Select One / New School Been Notified? Select One
Child: / Grade: / Start Date: / Ed Rights: limit:
New School: / Previous School: / IEP/IFSP: Select One
Child checked out of previous school? Select One / New School Been Notified? Select One

NEW PLACEMENT INFORMATION ER or ESH Placement? Select One

Facility Type: Select One / Date:
Name of Agency (if applicable): / Phone Number:
Name of Caregiver(s): / Caregiver Relationship: Select One
Address:
SW’s Name: / Worker #: / Phone #:
Secondary SW’s Name: / Worker #: / Phone #:
Authorized by (if different than SW):