Form 1 Long Term Foster Care Placement Memo

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

U.S. Department of Health and Human Services

OFFICE OF REFUGEE RESETTLEMENT
Division of Children’s Services
LONG TERM FOSTER CARE PLACEMENT MEMO
Type of long term foster care (LTFC) placement requested: Choose an item.
Minor’s Name: Click here to enter text.

A#: Click here to enter a date.

Foster care agency has found a placement for the above minor. Please use the foster care program address and phone
number for all contacts with the youth, including change of venue forms.
Foster care program:
Click here to enter text.

Program Address:
Click here to enter text.

Foster care program staff responsible for transfer:
Click here to enter text.

Phone #:
Click here to enter text.

Placement Type:
Traditional Foster Care

Therapeutic Foster Care

Other (Please specify): Click here to enter text. In Network?

Name of Foster Family:
Click here to enter text.

Group Care
Yes

Residential Treatment Center

No

Address:
Click here to enter text.

1. Describe how this placement meets the minor’s needs identified in the Case Summary and Individual Service Plan:
Click here to enter text.
2. Describe family, household, and community setting: Click here to enter text.
3. For an initial transfer into LTFC only (if a change of placement for a minor already in LTFC skip and move to 4):
a. Has a legal service provider or attorney found that the minor would be eligible for legal relief in the receiving
jurisdiction? Choose an item.
b. What is the name and contact information for the legal service provider or attorney of record who will arrange legal
services for the minor at the time of placement with your organization? Click here to enter text.
4. For a change of placement for a minor already in LTFC only (skip if this is an initial transfer into LTFC). What are the
reasons for the request? Click here to enter text.
In recommending the placement above, foster care agency has followed state guidelines and internal policies and procedures
in recommending this placement.
Foster care program staff: ______________________________ __________________ Date: ____________

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .10/hour
per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.