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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective

Date:

Volume:

X

Forms

Chapter:

A

Forms

4-6-2009

Subchapter:

1

Forms

Issuance:

25.59

CP&P Form 25-59, Residential Placement Agreement and/or Acknowledgement Between the State of New Jersey Division of Child Protection and Permanency and Parent(s), Legal Guardian, or Legal Custodian

 

Click here to view or print the CP&P Form 25-59, Residential Placement Agreement/Acknowledgement.

 

WHEN TO USE IT

 

The form provides:

      Authority for CP&P to place a child in a residential treatment center, group care facility, out-of-home treatment program, or emergency care facility by a parent(s)'s, legal guardian's, or a legal custodian's voluntary consent.

      A formal acknowledgement by a parent(s), legal guardian, or a legal custodian of the placement of his or her child through CP&P in a residential treatment center, group care facility, out-of-home treatment program, or emergency care facility as authorized by a court order.

Use the form to:

      Identify the role and responsibilities of the parent(s), legal guardian or legal custodian while the child is in residential placement;

      Acknowledge the cooperative effort between CP&P and the parent(s), legal guardian, or legal custodian in terms of planning for the child; and

      Emphasize the parent's responsibility to pay child support and/or medical support for his or her child in out-of-home placement through CP&P, while familiarizing the parent with child support collection procedures.

 

WHEN NOT TO USE IT

 

Do NOT use the form to authorize placement:

      When a child has been, or needs to be, removed from his or her home due to abuse or neglect; or.

      When placing a child in a youth shelter, if the child will be placed in a resource family home (i.e., a foster home or with a relative caregiver or a family friend) from the shelter.

Both situations require a court order to authorize the child's out-of-home placement

 

HOW TO USE IT

 

The child's Worker guides the parent(s), legal guardian, or legal custodian when completing the form:

      Enter a check mark to indicate how the child's placement in a residential setting is authorized: by parental consent or a court order;

      Give a copy of the residential placement agreement/acknowledgement form to the parent(s), legal guardian or legal custodian, for thorough review (all three pages);

      Read the form in its entirety, to the parent(s), legal guardian or legal custodian;

      Complete the front page, then remove the carbon paper insert from the form packet:

-       Separate the original copy (CP&P file copy) from the carbon copy (parent/legal guardian/legal custodian copy) of the form;

-       Turn over the original, CP&P file copy and the parent/legal guardian/legal custodian copy of the form, realign them with the client copy on the bottom, and reinsert the carbon paper, ink side down;

      Enter the parent(s)'s, guardian's, or legal custodian's identifying information;

      Obtain signatures from the parent(s), legal guardian or legal custodian. The Worker also signs the form.

The Supervisor/Casework Supervisor signs the form to acknowledge the child's placement (in the "For Official Use Only" box, on the bottom of page 2).

 

DISTRIBUTION

 

After the form is signed, distribute it as follows:

Original

Child’s Case Record

Copy

Parent(s), legal guardian, or legal custodian

Addendum

Give original/only copy to the parent(s).

Note: Discard the Addendum when completing the form with a child's legal guardian or legal custodian.