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PERMANENCY FORMS

CPYP counties and their partners have developed forms that relate to their permanency efforts. These include forms to capture information at the time of first contact with a possible permanent connection and tools to track progress and monitor outcomes. We hope these samples may assist other counties and agencies who are doing similar work.

 

Documenting Search Results

Contact Information (CPYP counties)
Worksheet used to document information on potential connections, including dates the potential connection appeared in the file, contact information, and follow up ideas.

Intensive Relative Search Contact Information (MS WORD)

 

Connections Tracking Form (Sonoma County)
Used by the family finding worker after making contact with the connection. In addition to tracking information, also aids in assessment by documenting involvement potential, legal issues, and safety issues.

Sonoma Tracking Form (MS WORD)

 

CPYP Search Sheet (Kern County)
Used to document search results from a wide variety of sources, including case mining, other social workers, court reports, etc. as well as Internet searches.

Kern CPYP Search Sheet (MS WORD)

 

Father Information (Sacramento County)
Used with new cases to gather important family information. The county has a comparable form for the mother.

Information Form for Father (MS WORD)

 

Maternal/Paternal Family Trees (Sonoma County)
Used to document both maternal and paternal family trees. Additional family members can easily be added.

Sonoma Maternal/Paternal Family Trees (MS EXCEL)

 

Questions for FFE for Youth (Kern County)
Series of questions to help youth identify potential connections.

Kern Questions for FFE for Youth (MS WORD)

 

Relationships/Connections (CPYP counties)
Comprehensive list of all known current and past maternal relatives, paternal relatives, caregivers, and other non-relatives such as godparent, friend, teacher, neighbor, etc.

Current Relationships/Past Connections of Affection (MS WORD)

 

Youth Connections (Sonoma County)
Form used to record information about possible connections for a given youth. In addition to basic contact information (address, phone, DOB, social security number, etc.), the form also captures medical and psychological history, and whether the youth or the connection wants contact.

Sonoma Youth Connections Form (MS EXCEL)

 

Organizational Development

Checklist on Agency Progress in Achieving Youth Permanency (CPYP)
Tool to track progress in fully implementing youth permanency work within an agency.

Checklist on Agency Progress (MS WORD)

 

Permanency Outcome Tracking

Monthly Services Form (Dumisha Project)
Form used to track amount and type of time worker spent doing permanency work, as well as updates to the youth's permanency plan, including connections made. The Dumisha Project is a five-year federal research project of Family Builders and Alameda County.

Dumisha Monthly Services Form (MS WORD)

 

Outcome Measures Tool (Rebekah Children's Services)
Outcomes tool used to track permanency outcomes, such as number of connections made and placement information. (Rebekah Children's Services is a multi purpose private FFA serving children in foster care.)

Rebekah Children's Services Outcome Tool (MS WORD)

 

Permanency Review Forms

Permanency Assessment Form (Sacramento County)
Form to be completed as part of the agency court requirement. Can also be used for case review.

Permanency Assessment Form (MS WORD)

 

Supervisor/Social Worker Tracking on Child & Youth Permanency (CPYP)
Chart to help track progress of cases. Completion dates are entered for each step of the permanency process, beginning with termination of FR services and ending with finalization of Permanency Plan.

Supervisor/Social Worker Tracking on Child & Youth Permanency (MS WORD)

 

Youth Permanency Consult Sheet (CPYP)
This tool is designed to be used as a framework for staffing or discussing cases on permanency. The tool assures that (1) information is shared in a concise way, (2) permanency is the focus of the discussion, (3) tentative permanency plans are set, and (4) specific next steps are set to forward the search for the youth's permanency.

Youth Permanency Consult Sheet (MS WORD)

 

Permanency Team Meetings

Confidentiality Agreement: Lifelong Connections Multi-Disciplinary Team (Sonoma County)
As a condition of participation in their Lifelong Connections Multi-Disciplinary Team meetings, Sonoma County requires all members to sign a confidentiality agreement.

Sonoma Confidentiality Agreement: Lifelong Connections Multi-Disciplinary Team (MS WORD)

 

Permanency Conference Brochure (Monterey County)
A permanency conference is a meeting for and about youth in long-term foster care. The meeting is youth-driven and is held to help youth think about their short-term and long-term goals. This brochure describes what a permanency conference is.

Permanency Conference Brochure (MS WORD)

 

Referrals

Internet Search Form (Sonoma County)
Form to initiate an Internet search for family from a designated county search worker. All counties use free Internet search engines and many use a fee-based search engine for their family finding work.

Lifelong Connections Search Request (MS WORD)

 

Permanency Family Finding and Engagement Referral Form (San Luis Obispo County)
Form used by county social workers to refer a youth to a permanency case manager.

SLO FFE Referral Form (MS WORD)

 

Permanency Program Referral Form (San Mateo County)
Form used by county workers to refer a youth to the permanency worker, who then begins family finding and engagement.

San Mateo Permanency Program Referral Form (MS WORD)

 

Search Tool (Stanislaus County)
Form used by a youth to initiate a search for family members. The youth fills it out and gives it to her or his assigned worker.

Youth Search Request (MS WORD)

 

Youth and Siblings Referral Form (Dumisha Project)
Form used by county workers to refer a youth and his or her siblings to the Dumisha Project, a five-year federal research project of Family Builders and Alameda County.

Dumisha Youth and Siblings Referral Form (MS WORD)

 

Sustaining Connections

Declaration of Intent to Maintain Contact (Project Uplift)
This form was developed by Cheryl Jacobson as part of Project Uplift/Adolescent Connections funded by an Adoption Opportunity Grant received by Colorado. She attributes the successfulness of utilizing the form to two factors: (1) it is very clear to both the adolescent and the connection adult what the commitment will entail, i.e., frequency of contacts, etc.; and (2) from "change theory" it is known that if a person makes a formal written agreement then the desired behavior is much more likely to happen.

Blank Form (MS WORD)

Completed Sample pdf

 

Monthly Items to Support a Youth (Kern County)
Form used with reconnected families to suggest activities to maintain their connection/reconnection with a youth and show support. Can also be used by families that are working toward reunification.

Monthly Items to Support a Youth (MS WORD)

 

Permanency Pact (Foster Club)
A Permanency Pact is a pledge by a supportive adult to provide specific supports to a young person in foster care with a goal of establishing a lifelong, kin-like relationship. This tool contains the actual Permanency Pact, along with an explanation and procedure for forming the pact.

Permanency Pact pdf

 

Post-Adoption Requests for Birth Family Information (Contra Costa County)
Contra Costa County has developed four letters in response to adoptees requesting information about their birth family, including siblings, and to birth parents seeking information about their adopted children:

Response to initial request from adoptee regarding birth parents. Includes State of California Consent for Contact Form.

Post Adopt Request for Birth Parent Info Letter (MS WORD)

Response to initial request from birth parent regarding her or his child who has been adopted. Includes State of California Consent for Contact Form.

Post Adopt Request from Birth Parents Letter (MS WORD)

Response to request from adoptee regarding sibling(s). Includes State of California Sibling Waiver.

Post Adopt Sibling Letter (MS WORD)

Response to adoptee after Consent for Contact Form has been received. Includes all non-identifying information which the county is allowed to provide.

Post Adoption Non Identifying Info Letter (MS WORD)

 

Stuff for Youth

YEAH! (Youth Excellence, Achievements and Happenings) Form (Monterey County)
Tool to celebrate and document success in the life of a foster youth. Items can include possible permanent connections, a positive incident or attribute, or individual achievements.

YEAH! Form (MS WORD)

 

Training Tools

Adolescent Permanency (Stanislaus County)
Pre- and post-permanency training tool

Survey of Adolescent Permanency (MS WORD, legal size)