Form Dshs 15 092 – Fill Out and Use This PDF

TO: NAME OF RECEIVING STATE	FROM:	Washington ICPC
		Department of Social and Health Services
		1115 Washington Street SE
		P.O. Box 45711
		Olympia, WA 98504

NOTICE IF GIVEN OF INTENT TO PLACE CHILD

IDENTIFYING DATA

CHILD’S NAME (LAST, FIRST, MI)					SOCIAL SECURITY NUMBER			DATE OF BIRTH
SEX		PRIMARY RACE						IV-E ELIGIBLE
Male	Female							Yes	No
MOTHER’S NAME					FATHER’S NAME
NAME OF AGENCY OR PERSON RESPONSIBLE FOR PLANNING FOR CH ILD								TELEPHONE NUMBER
STREET ADDRESS					CITY		STATE		ZIP CODE
NAME OF AGENCY OR PERSON FINANCIALLY RESPONSIBLE FOR CHILD
STREET ADDRESS					CITY		STATE		ZIP CODE
			PLACEMENT INFORMATION
NAME OF PERSON OR FACILITY CHILD IS TO BE PLACED WITH								TELEPHONE NUMBER
PHYSICAL ADDRESS					CITY		STATE		ZIP CODE
TYPE OF CARE
Foster Family Care			Parent				Adoption
Group Home Care			Relative (not parent)				Subsidy/IV-E Assistance
Residential Care Center			Specify Relationship:			To be finalized in:
Child Caring Institution			Other (Specify):				Sending State
Institution Care (Article VI)							Receiving State
LEGAL STATUS
Sending Agency Custody/Guardianship				Parental Rights Terminated – Right to Place for Adoption
Parent Relative Custody/Guardianship				Unaccompanied Refugee
Court Jurisdiction Only				Other (Specify):

SERVICES REQUESTED

INITIAL REPORT (IF APPLICABLE)	SUPERVISORY SERVICES	SUPERVISORY REPORTS
Parent Home Study	Request Receiving State to Arrange	Quarterly
Relative Home Study	Supervision	Semiannually
Adoptive Home Study	Another Agency Agreed to Supervise	Upon Request
Foster Home Study	Sending Agency to Supervise	Other (Specify):

NAME OF SUPERVISING AGENCY IN RECEIVING STATE

STREET ADDRESS	CITY	STATE	ZIP CODE
DSHS 15-092 (REV. 01/2009)

ENCLOSED

Child’s Social History		ICWA Enclosure	Other Enclosures
Home Study of Placement Resource		Financial/Medical Plan
Court Order		IV-E Eligibility Documentation
SIGNATURE OF PERSON OR SENDING AGENCY REPRESENTTIVE				DATE
SIGNATURE OF SENDING STATE COMPACT ADMINISTRATOR OR ALTERNATE				DATE
		ACTION BY RECEIVING STATE
Placement may be made		REMARKS
Placement shall not be made
SIGNATURE OF RECEIVING STATE COMPACT ADMINISTRATOR OR ALTERNATE				DATE

DSHS 15-092 (REV. 01/2009)

ICPC Placement Request Instructions

In the first block, enter the name and state of the ICPC Administrator (or Deputy) whose state is submitting the request. FROM: This is the state including address from which the request is originated.

Notice is given of intent to place child

Identifying Data

Fill out one form per child to be placed. Enter the full legal name, Social Security number, date of birth, sex, and primary race. Place an “X” in the “Yes” or “No” box which is designated for IV-E eligibility. Enter the names of the legal mother and the legal father. In most instances the legal mother and legal father will be the birth parents. In cases where an adoption has been finalized, the adoptive pa rents will be the legal parents. If the parent(s) is deceased, enter “deceased” after the parent’s name. If parental rights have been voluntarily relinquished or terminated by the court, indicate in parenthesis beside the name. If you prefer in that instance to withhold the name, simply enter the status of the parent’s rights.

Enter the complete name, address and telephone number of the agency or person who is responsible for planning for the child and who is financially responsible for the child. In most instances, these two items will be the same (the sending agency).

Placement Information

Enter the full name, address, and telephone number of the person(s) or facility with whom the sending agency proposes to place the child.

Place an “X” in the box which designated ONE of the following Types of Care Requested.

Foster Family Home: A foster family home is a facility providing care and guidance for a child or children not related to the caretaker for regular 24 hour care, or a certified kinship care home. A family foster home may not operate without a license or a certificate as required by the laws of the receiving State.

Group Home Care: A resource which is licensed or approved as a group home and provides substitute care for a fee. Usually a modified family type setting which serves more children that a foster home, but fewer than an institution.

Residential Treatment Center: A group care facility which provides a specific treatment program outside the realm of a medical hospital, psychiatric hospital or institution for the mentally ill, e.g. a residential program for the treatment of alcohol/drug abuse. The receiving state is not obligated to supervise this type of placement made by the sending state.

Parent(s): Legal parent(s).

Relative (not parent): Specify relationship, such as maternal aunt, paternal grandparents, brother, etc.

Other: Specify a type of care not already listed, e.g., Non-Relative Free Home (an unrelated family which does not require foster home licensure in the receiving state and does not need or want foster care payments). Independent Living Arrangement (an older teenager who is still under the jurisdiction of an agency or court but is capable of independently living without the supervision of a foster home or group home), or Maternity Home.

Adoption: Refers to both agency and private/independent adoptive placement prior to finalization, this may refer to an initial placement with a family where adoption is the intention, or it may refer to the movement of an adoptive family from State A to State B following placement. Indicate if a federally funded adoption subsidy (Title IV-E) or a state funded subsidy (non IV-E subsidy) is applicable, mark in which state the adoption is to be finalized.

Place an “X” in the box, which designates one of the following kinds of Legal Status.

DSHS 15-092 (REV. 01/2009)

Sending Agency Custody/Guardianship: The child is in the full legal custody or guardianship (depending on the

terminology of the state) of a public agency. For example: a public agency may be social services, youth corrections, probation/parole, or a tribe. The sending agency may also be a licensed private child placement agency, an adoption agency, or a birth mother if allowed by state law.

Parent/Relative Custody/Guardianship: The child is now under the jurisdiction of either an agency or the court but is the full legal responsibility of the parent or relative most likely to be marked when a parent/relative/or guardian wishes to place a child in one of the types of care listed on the previous page.

Court Jurisdiction Only: The child is not the legal responsibility of an agency, the court has full responsibility for weighing the requested information and making the placement decision and is, therefore, the sending agency, most likely to be marked when two or more relatives have taken a dispute over custody into court and at least one of the disputing relatives is not a parent.

Parental Rights Terminated – Right to Place for Adoption: The sending agency has accepted a voluntary relinquishment of parent rights and/or has completed court action terminating parental rights and now holds complete jurisdiction over the child with the right to place for adoption.

Unaccompanied Refugee Minor: This form is not used to report the initial placement into the United States, but to request placement and services in a second state after a U.S. agency or court has been granted full legal responsibility (custody/guardianship). Mark this block only if that is the case; also mark the Sending Agency Custody/Guardianship block. If this is an Unaccompanied Refugee Minor whose status warrants DSHS 15-092’s specific to those children (not legal responsibility of a U.S. agency or court), do not use this form.

Other: Legal status is not otherwise listed, e.g., legal action, such as a petition for custody/guardianship or to terminate parental rights, is pending, e.g., the child is the responsibility of the sending agency under a Voluntary Agreement with the parent or legally responsible relative and no court action has been taken or is pending to alter that family member’s legal rights over the child.

Specify:

Services Requested

Initial Report Requested: (IFAPPLICABLE) If the proposed placement is not for a group care placement and a current home study has not yet been received, mark the box for the appropriate type of home study needed based on the type of care indicated. Place an “X” in one of the following boxes to indicate which Initial Report is applicable.

Parent Home Study: Mark this box is you require a Parent Home Study.

Relative Home Study: Mark this box if you require a Relative Home Study.

Adoptive Home Study: Mark this box if you require an Adoptive Home Study.

Foster Home Study: Mark this box if you re quire a Foster Home Study.

Supervisory Services: Place an “X” in one of the following boxes to indicate how Supervisory Services are to be conducted:

Request Receiving State to Arrange Supervision: Mark this box if the sending agency cannot supervise and does not have a contractual or other agreement with a pre-determined agency to provide these services; it is usually the public social service agency which will be asked to provide supervision following an approved home study and subsequent placement.

Another Agency Agreed to Supervise: Mark this box if the sending agency already has received the formal agreement of a pre-determined supervisory agency; most likely to be marked in agency adoptive placements where an agency in the receiving state already has provided an adoptive home study and will be providing ongoing services to the adoptive family. Do not mark this I tem simply because you know which county office of the public agency will receive this referral and might even have discussed the case over the telephone; that does not constitute an agreement to supervise.

Sending Agency to Supervise: Mark this box if it is logistically feasible, it is the best case plan, and the receiving state has granted the sending agency permission (which may or may not include licensure) to provide services in its state.

DSHS 15-092 (REV. 01/2009)

Supervisory Reports Requested: To be completed even though placement may not be a certainty at this time. Indicate how frequently you wish to receive progress reports; most common is Quarterly. Another option is Semiannually. Be very discriminating in your use of Upon Request because that leaves the provision of supervision open ended with no commitment to provide that service until you request it; use Other when you wish to receive reports in a less usual time frame, such as monthly or annually (specify the time frame).

Name and Address of Supervising Agency in Receiving State: If you know the name and address of the supervising agency, type that information onto the line so indicated. If not known by the sending agency, that information should be completed by the receiving state’s Compact Office following receipt of a recommendation indicating that placement may be made.

Enclosed: Indicate which Items are enclosed.

Child’s Social History: This should accompany the majority of referrals; includes the pre-placement summary on adoption referral and can be written with non-identifying information, if appropriate and preferred.

Home Study of Placement Resource: Attach a current home study if one is not being requested; most likely to be marked if you already have an approved home study or the child is re-locating with foster parents and the foster home study is enclosed.

Court Order: All applicable court documents should be enclosed; e.g., custody/guardianship orders, surrenders, orders terminating parental rights, and orders requesting a home study for the court.

ICWA Enclosure: Obtain a letter from the child’s Tribe showing that the child is a member or is eligible for membership.

Financial/Medical Plan: Attach the plan of how the proposed placement will be funded and how the child/children’s medical needs will be covered.

IV-E Eligibility Documentation: Attach a copy of the determination of IV-E eligibility.

Other Enclosures: Indicates other pertinent materials such as psychological evaluations, permanency plan, medical reports and school reports; it is not necessary to itemize them on the form.

Signature of Person or Sending Agency Representative and Date Signed: The form should be signed and dated by anyone outside of the Compact Office who is completing the form; includes a person with this authority in the county social services agency, private agency, or court and any private individual or family member who is legally responsible for the child.

Action by Receiving State

This section is completed by the Compact Administrator, Deputy, or alternate in the receiving state. The designated person reviews the proposed placement and all required information. Place an “X” in one of the following boxes to indicate IF Placement may be made or IF Placement shall not be made. Remarks might include conditions or reservations to be noted. The Compact Administrator, Deputy, or alternate then signs and dates the form.

DSHS 15-092 (REV. 01/2009)