Missouri Department of Social Services,

Children’s Division

VOLUNTARY PLACEMENT AGREEMENT

Introduction:

This document is to establish a voluntary placement agreement, herein after referred to as the VPA, for the below child whom the Department of Mental Health has identified as eligible for their services and in need of a temporary out-of-home placement.

Child’s full name
Date of birth	Social Security Number

This agreement is between the following parties:

The parent(s)/legal guardian(s)/custodian(s) of said child, herein referred	to as “the parents”, and

2.	the Missouri Department of Social Services, Children’s Division, herein

referred to as CD.

This agreement must be signed by the CD Central Office designee before it will be considered officially approved, and a placement made.

Agreement:

CD and the parent(s) of the child are parties to this agreement and agree to the following:

1.	The parties agree that this VPA is being entered into under the authority of §210.122 RSMo., 13 C.S.R. 35-30.010 and 42 U.S.C. §672 and is subject to the following conditions:

a.	The above parties agree to enter into this VPA for the placement of the child who is seventeen years or younger into an out-of-home placement;

b.	The parties agree that the placement is needed solely because the child is in need of mental health treatment;

c.	As a condition precedent the implementation of this VPA DMH must determine that placement is appropriate and it is solely due to the child’s need for mental health treatment.

d.	If all of the lawful requirements of a VPA have been met CD authorizes DMH to place the child and to provide mental health care and treatment.

e.	Any function that CD has delegated to DMH regarding the placement and care of the child shall be administered by CD to ensure compliance with federal and state law.

2.	The parties to this VPA agree and understand that the parent(s)/legal guardian(s)/custodian(s) retain legal custody of the child during the child’s placement and the child is not under Juvenile Court jurisdiction.

3.	The Department of Mental Health has the authority to place the child, administer and supervise the placement, and provide care and treatment and case management services for the child while he/she is under the VPA. Except in emergency situations, no change in placement is to be made without prior notice to the parent(s), DMH and CD. Unless there is an emergency or the parents terminate this voluntary placement agreement, the CD shall assure a Family Support Team [FST] Meeting is held to discuss the needs of the child and any contemplated change in placement.

4.	The parent(s) will obtain a medical examination of the child prior to placement. If the parent is unable to obtain such an examination prior to placement, the medical examination shall be arranged by the parent within 72 hours of placement.

5.	All parties agree to participate in a Family Support Team Meeting to develop a mutually agreed upon permanency/treatment plan prior to placement, or no longer than 72 hours after placement. The parties will comply with provisions of the permanency/treatment plan and will maintain regular contact as specified in the plan.

6.	The parties may convene additional FST meetings as the parties deem necessary during the placement. All parties agree to attend and participate in all FST Meetings. In addition to the FST meeting described in the paragraph above, the following additional mandatory FST meetings shall be held:

An FST meeting shall be scheduled to occur around and no later than 100 days after the execution of this agreement and placement of the child under this VPA. The purpose of this FST meeting is to review the child’s progress during the placement, conduct an assessment of the child’s need for continuing treatment and begin to plan for the care and treatment for the child after the VPA terminates.

b.	An additional FST shall be scheduled to occur around and no later than 150 days after the execution of this agreement and placement of the child under this VPA. The child and family’s progress will be reviewed to ensure appropriate transition planning occurs prior to the termination of the VPA.

7.	The parent(s) will notify the designated care manager or his/her supervisor of any changes in family composition, phone number, address, employment, income, health care coverage or other information critical to case management decisions.

8.	The parent(s) will continue to take an active role in decision making regarding their child and remain an active partner in the implementation of the mutually agreed upon treatment plan. This includes, but is not limited to participating in all FST meetings.

9.	Should an emergency arise where immediate medical attention is needed and the parent(s) is unable to authorize such attention, the placement provider has authority to seek emergency medical care. The parents may be liable to pay for the costs of that treatment to the extent that the costs are not covered by Mo HealthNet or other insurance.

10.	Due to the parent retaining legal custody of the child, the parent agrees to a referral to Child Support Enforcement (CSE) and further agrees to bear financial responsibility for the child to the extent that the parent is able.

11.	If the parent(s) receives SSI benefits for the youth, it is the parent(s) responsibility to contact the Social Security Administration and inform them of the out-of-home placement.

12.	This mutual agreement is effective the date the child is placed. The placement shall be in the least restrictive setting and for the shortest amount of time, as clinically indicated. Under no circumstances shall the term of this agreement exceed 180 days from the effective date of this agreement. There is no right for any party to request renewal of this VPA. This agreement will automatically terminate on the date that the child returns home.

13.	In the event that the team or the CD determines that the child cannot be returned home, the parent(s) are unable to provide necessary care beyond the termination date of the VPA or that other grounds for the assertion of the jurisdiction of the juvenile court under 211.031.1 may exist, CD shall prepare a report and a referral to the Juvenile Officer for the filing of a petition in juvenile court as required by §210.710.1 211.031.1(1)(d) RSMo., 42 U.S.C. §672 and/or other applicable law. If the JO declines to file a petition or to take other appropriate action the child shall be returned to the child’s parent(s) and the VPA shall automatically terminate. The parties agree that DMH and CD may share any and all information which DMH and/or CD obtains with the Juvenile Officer and the Juvenile Court.

14.	Failure to follow the conditions of the permanency/treatment plan could lead to a referral to the juvenile court and/or termination of the placement agreement.

15.	This agreement will be terminated if the parent(s) or the child moves outside the State of Missouri or if the parent(s) no longer desires to be reunified with their child. This agreement may be terminated by DSS/CD upon ten days notice.

16.	The parent(s) may terminate this agreement for any reason at any time. However, the parents understand that if CD determines that termination of this agreement may jeopardize the health, safety and welfare of the child or that other grounds may exist for the assertion of juvenile court jurisdiction CD has the option of sending a referral and recommendation to the Juvenile Officer at any time.

Sign-off of Parties

Date:

Parent/legal guardian

Date:

Parent/legal guardian

___________________________________________________________Date:

CD designee

___________________________________________________________Date:_____________________

CD Central Office designee

Placement Provider
Daily Rate

Effective Date of Placement

After approval is received, the CD Custody Diversion Protocol designee will send a copy of the agreement to the local DMH Administrative Agent, Regional Office, or Adolescent CSTAR provider responsible for placement. The local DMH provider should return a copy of the agreement with the identified placement date to the local Custody Diversion Protocol designee. This should be completed within 5 days of placement. If the agreement is not returned with a placement date within 5 days the local CD Custody Diversion Protocol designee should contact the DMH Administrative Agent, Regional Office or Adolescent CSTAR provider to request the begin date.

The local CD Custody Diversion Protocol designee must send a copy of the signed agreement with the identified placement date to the Residential Care Screening Team Coordinator and the Central Office designee responsible for the oversight of the VPA program within 10 days from receipt of the signed agreement with the placement date added.