Passport to Placement

1. Aero Success We Strive for Excellence Passport to Placement

2. 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.

3. Fulton County Department of Family and Children Services 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) ●

4. Fulton County Department of Family and Children Services PLACEMENT PASSPORT This Passport Belongs To: 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-Ply Provider Foster Parent Resource Center Foster Care Unit

5. Fulton County Department of Family and Children Services ALL ABOUT ME! 4-Ply Provider Foster Parent Resource Center Foster Care Unit

6. Fulton County Department of Family and Children Services 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. 4-Ply Provider Foster Parent Resource Center Foster Care Unit

7. 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 EXPECTED BIRTH 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: _________________ 4-Ply Provider Foster Parent Resource Center Foster Care Unit

8. Fulton County Department of Family and Children Services PLACEMENT 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: ____________________ 4-Ply Provider Foster Parent Resource Center Foster Care Unit

9. Fulton County Department of Family and Children Services 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 Provider Foster Parent Resource Center Foster Care Unit

11. Fulton County Department of Family and Children Services 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  No Where 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: _____________ 4-Ply Provider Foster Parent Resource Center Foster Care Unit

12. 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 Familyand 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:_________ 4-Ply Provider Foster Parent Resource Center Foster Care Unit

13. Fulton County Department of Family and Children Services 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: __________ 4-Ply Provider Foster Parent Resource Center Foster Care Unit Form 58

14. Fulton County Department of Family and Children Services 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: ________ 4-Ply Provider Foster Parent Resource Center Foster Care Unit

15. Fulton County Department of Family and Children Services 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 Representative Fulton County Department of Family and Children Services _____________________________ Date 4-Ply Provider Foster Parent Resource Center Foster Care Unit

16. Fulton County Department of Family and Children Services 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: ___________ OFFICE LOCATION: FULTON COUNTY FAMILY RESOURCE CENTER (404) 762-4000 3-Ply Provider Resource Center Foster Care Unit 3-Ply Provider Resource Center Foster Care Unit For contractual issues contact your Regional Supervisor Opum Main (404)657-3572

17. Fulton County Department of Family and Children Services AGREEMENT SUPPLEMENT (DFCS Foster Parent) _________________County Department of Family and Children Services Case 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 Services Form 40 3-Ply Foster Parent Resource Center Foster Care Unit

19. Fulton County Department of Family and Children Services 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/childrenlisted (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: ____________ 4-Ply Provider Foster Parent Resource Center Foster Care Unit

20. Fulton County Department of Family and Children Services Personal Property Inventory (Entering Home) Child’s Name: Date: 4-Ply Provider Foster Parent Resource Center Foster Care Unit

21. Fulton County Department of Family and Children Services Personal Property Inventory (Exiting Home) Child’s Name: Date: 4-Ply Provider Foster Parent Resource Center Foster Care Unit