R-9 Category 4 Discharge Plan
Release of Unaccompanied Children from ORR Custody
Category 4 Discharge Plan (Form R-9) - PDF
OMB: 0970-0552
OMB 0970-0552 [valid through MM/DD/YYYY]
Administration
for Children & Families
Office of Refugee Resettlement
Category 4 Discharge Plan
This Discharge Plan may not be shared with the Department of Homeland Security (DHS). DHS will be notified of the individual’s discharge from ORR care via the Discharge Notification Form in accordance with the UC Manual of Procedures (UC MAP).
Category 4 cases are cases where a child does not have an identified sponsor and release to an approved sponsor may not be possible. In such cases, care providers are responsible for creating discharge plans to address the individual needs of each child following their discharge from Office of Refugee Resettlement (ORR) care. Whenever possible in Category 4 cases, care providers should discharge the child to the care of an appropriate individual or agency. It is recommended that this Category 4 Discharge Plan be reviewed and signed by the individual to whom the child is being released or the agency supporting and providing services to the child after release, with the child’s consent (See Part 3).
Case managers must develop a Discharge Plan for Category 4 children with complex discharge cases, such as children who are:
Seeking lawful immigration relief
Entering into the Unaccompanied Refugee Minor (URM) Program
Aging out of ORR care (Post-18)
Being discharged to a licensed non-profit
Seeking voluntary departure
For those who are aging out of ORR care, this Discharge Plan must be developed at least 2 weeks in advance of their 18th birthday, if possible (see H. Rept. 116-450). This is a living document that should be revisited continuously and updated no later than 24 hours before the child is discharged from ORR care.
Note: In cases where the child is able to be reunified with an approved Category 1-3 sponsor, please enter the date of Discharge Plan Form closure. [date format xx/xx/xxxx] |
Child’s Basic Information |
Name:[text] Date of birth:[date format xx/xx/xxxx] A number:[Number format xxx-xxx-xxx] Country of origin: [text] Planned location of residence (city/state): [text] |
PART I: PLANNING FOR DISCHARGE
Do not share Part 1 with individual/agency receiving the unaccompanied child (or former unaccompanied child.)
Family Group |
Skip if going to URM
Is the unaccompanied child part of a family group (For example, they have a sibling in the Unaccompanied Children (UC) program)? Y__ N__
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Case Management Needs |
Skip if going to URM
Bio/case summary: [text] Case management support needs: [text]
Child’s strengths: [text] Child’s protective factors: [text] Child’s special needs: [text] What is the assessment and recommendation of any ongoing supporting social services the child may require? [text] List any known potential safety concerns or things to be aware of upon release. [text]
Was an individual safety plan created, if applicable? Y__ N__Pending__ Individual safety plan date: [date format xx/xx/xxxx] Was the individual safety plan sent to the program/individual receiving the child? Y__ N__ Did the program/individual receiving the child sign the safety plan? Y__ N__
Does the child have information on who to contact if they feel unsafe when they leave care? Y__ N__ Has the child given ORR consent to reach out to them or to a point of contact (i.e., an emergency contact) if ORR wants to verify their safety after release? Y__ N__ ORR’s outreach occurs only with a child’s consent, or whether it occurs as a matter of course for all children released from ORR care.
Future case manager information (if applicable): Name: [text] Phone Number: [text] Program: [text] Address: [text] City: [text] State: [dropdown] Zip Code: [text]
For children who are eligible for refugee benefits and services, they may receive case management services through a local refugee resettlement program (cash and medical assistance, mental health, case management, employment, savings programs, ESL, school supports, mentoring, etc.) Was a referral to a refugee resettlement program initiated? Y__N__ If yes, future case manager information: Name: [text] Phone Number: [text] Program: [text] Address: [text] City: [text] State: [dropdown] Zip Code: [text]
|
Family Unification Plan |
Skip if going to URM
Has the care provider connected them with family who were identified as potential sponsors but did not complete the sponsorship process? Y__N__
Describe any family unification options: [text]
Home study date completed, if applicable:[date format xx/xx/xxxx]
Do they have any other connections with family in home country and/or in the U.S.? Please describe: [text] |
Legal Services Plan |
This section should be filled out for all Category 4 children who receive (or are anticipated to receive) lawful immigration relief. If a care provider determines that a child may have a lawful immigration relief option, the case manager notifies the FFS immediately for consultation. If a legal service provider (LSP), attorney of record, or a child advocate notifies the case manager that the child may be granted lawful immigration relief, the case manager notifies the FFS of the need for a Discharge Plan. The LSP, attorney of record, or child advocate works with the child, case manager, FFS and other stakeholders to develop the Discharge Plan.
For children who meet eligibility criteria for the URM Program, case managers must create a Discharge Plan in consultation with an LSP, attorney of record, or child advocate. The case managers must complete this section if URM is designated as their post-UC program placement. Once an ORR approval letter is received from the URM Program, the care provider immediately facilitates and coordinates the transition into the URM Program.
STAKEHOLDER CONTACT INFORMATION AND RECOMMENDATIONS
Current attorney of record contact information: (if applicable) Name: [text] Phone: [text] Email: [text] Address: [text] City: [text] State: [text] Zip Code: [text] List the attorney of record’s recommendations: [text]
Current LSP contact information: (if applicable) Name: [text] Phone: [text] Email: [text] Address: [text] City: [text] State: [text] Zip Code: [text] List the LSP recommendations: [text]
Current child advocate contact information: (if applicable) Name: [text] Phone: [text] Email: [text] Address: [text] City: [text] State: [text] Zip Code: [text] Date of child advocate’s best interests determination: [date format xx/xx/xxxx] List child advocate’s recommendation: [text]
CURRENT IMMIGRATION CASE Does child understand they have a pending immigration case? Y__N__ Have they spoken with the LSP and/or attorney of record? Y__N__Pending__ Do they understand that they have to appear in immigration court? Y__N__Pending__ Next court date: [date format xx/xx/xxxx] https://acis.eoir.justice.gov/en/ Describe current immigration status (include reference to specific milestones or notices): [text] List immigration related petitions that have been filed: [text] Type of immigration related petitions filed: [text] Date of filing:[date format xx/xx/xxxx] Status/updates (i.e., upcoming or completed biometrics appointment): [text] STATE/DEPENDENCY COURT PETITIONS List the state/dependency court petition that has been filed:[text] Type of state/dependency court petition filed:[text] Date of filing:[date format xx/xx/xxxx] Status/updates: [text] OFFICE ON TRAFFICKING IN PERSONS (OTIP) REFERRALS Does the child have a pending case with OTIP, an Interim Assistance (IA) Letter, an OTIP Eligibility Letter, or any potential trafficking concerns? Y__N__Pending_ If yes, has a referral been made to OTIP’s Aspire or TVAP programs? Provide updated information about the child’s post-release location, contact information, and trafficking concerns. [Yes] [date format XX/XX/XXXX] If yes, has this OTIP letter been shared with the child's attorney of record? Y__N__ If yes, or pending, has OTIP been notified of the child’s future address? Y__N__ If yes, or pending, does the child have the letter in their possession? Y__N__
Has the child been referred to OTIP within 30 days of release to receive resources and referrals from OTIP for the city/state they will reside in? Y__N__ If yes, enter date of OTIP referral: [date format XX/XX/XXXX] If no, please explain: [text]
If there are trafficking concerns, has a Request for Assistance (RFA) been submitted to OTIP?: Y__N__ Does the child have the letter in their possession, or has a new address been provided to OTIP?: Y__N__ Has a referral for case management services been submitted through Aspire or the Trafficking Victim Assistance Program (TVAP)?: Y__N__ Aspire or TVAP provider information (if applicable): [text] Name: [text] Address: [text] City: [text] State: [text] Zip Code: [text]
REFUGEE BENEFIT ELIGIBILITY At the time of discharge, does the child have a status that makes them eligible for refugee benefits?_ Y__N____Pending If yes (and if not going to URM), has a connection been made to a refugee resettlement agency? Y__N__Pending__
EMPLOYMENT AUTHORIZTION Has an Employment Authorization Document (EAD) been received? Y__N__Pending__ Date EAD issued: [date format xx/xx/xxxx] Date EAD expected to be issued, if known: [date format xx/xx/xxxx] Any other updates: [text]
RELEASE Expected release date from ORR: [date format xx/xx/xxxx] Expected lawful immigration relief or status upon release: [text] If the child has received lawful immigration relief or status (I-360), what is their projected length of stay [insert number] Explain why they are not being immediately discharged from ORR: [text]
If a state is involved with a child’s guardianship, has the program obtained approval to discharge the child to a sponsor Y__N__ Children who are in ORR custody, and eligible for Special Immigrant Juvenile (SIJ) classification, must obtain specific consent if they are seeking state court jurisdiction to make dependency findings and a change of custody or placement. https://www.uscis.gov/working-in-US/eb4/SIJ
Does the child have any federal, state or local civil or criminal charges or arrests? Y__N__ If yes, state any upcoming court dates: [text] |
Voluntary Departure |
Skip if going to URM
Is the child pursuing voluntary departure? Y__ N__ Did the immigration court grant voluntary departure? Y__ N__ If yes, on what date was it granted? [date format xx/xx/xxxx] If yes, on what date must the child leave the U.S.? [date format xx/xx/xxxx] If no, when is the child’s court date scheduled? [date format xx/xx/xxxx]
Is there a child advocate appointed (see UC Policy Guide Section 2.3.4 Child Advocates)? Y__ N__ Was a Best Interest Determination considered in this case? Y__ N__
Are there identified services that are recommended for the child? [text]
Skip to Transportation Plan For Voluntary Departure Cases |
Release to DHS ICE FOJC Upon Age Out |
Skip if going to URM
Did the care provider notify the local DHS Immigration and Customs Enforcement (ICE) Field Office Juvenile Coordinator( FOJC) that the child will age out? Y__ N__ If yes, did the care provider obtain in writing whether the DHS ICE FOJC will be providing the child with a release on their own recognizance? Y__ N__ Release on one’s own recognizance is a decision made by ICE to allow a person to remain at liberty while still in removal proceedings as an alternate to detention. |
Transportation Plan |
Skip if going to URM
What are the transportation arrangements from the care provider to the Post-18 placement? [text] The care provider must arrange for the child to be transported to the individual where they will be staying. Once the child ages out, ORR is not authorized to pay for travel. If possible, the care provider should explore alternative arrangements for transport costs. If there are extenuating circumstances, ORR may cover the cost, in exigent circumstances, but the case manager should plan to arrange for and pay for the transport (such as airline tickets, etc.) before the child turns 18. What is the plan for transfer to DHS, where appropriate? [text]
If the child is seeking voluntary departure, what are the transportation arrangements from the ORR care provider? [text] Did the child contact parents and/or legal guardians in their home country: Y__ N__ Who will be receiving the child upon their arrival in home country?: [text] Contact information of parents and/or legal guardians in home country: [text] Date of anticipated departure: [date format xx/xx/xxxx] Has the consulate issued travel documents? Y__ N__ The transportation plan must include delays due to weather and any other unforeseen circumstances. |
Health Discharge Safety Plan |
See UC Policy Guide Section 3.4.7 Maintaining Health Care Records and Confidentiality and UC Policy Guide Section Protecting Confidentiality of Mental Health and Medical Records. Clinical assessments and medical health records are protected from release without consent from the child. The care provider should provide all health records to the child directly if they are 18 or older (since they would be authorized to receive their own records as an adult).
HEALTHCARE NEEDS THAT REQUIRE FOLLOW-UP CARE Does the child have any ongoing medical, mental health or dental needs that require follow-up care? Y_ N_
If yes, and a post-release follow-up appointment has been scheduled, complete the following table:
If yes and a post-release follow-up appointment has not been scheduled, complete the following table:
If yes, have all ongoing diagnoses and care been reviewed and explained to the child. Individual/program to whom the child is being released, with the child’s permission? Y__ N__. If no, why not? [text]
HEALTHCARE PROVIDERS Has a primary care provider (PCP) been established for the child after release? Y__ N__. If no, why not? [text] If yes, enter the PCP’s contact information: Name: [text] Phone number: [text] Email: [text] Physical address: Address: [text] City: [text] State: [text] Zip Code: [text]
Enter the contact information for the child’s PCP while in ORR care: Name: [text] Phone number: [text] Email: [text] Physical address: Address: [text] City: [text] State: [text] Zip Code: [text]
List federally qualified health centers (FQHC) and addresses that are located around the child's post-release destination:
MEDICATION Will the child be taking medications when they leave ORR care? N__ Y__, complete table below:
Has the Case Manager identified a mechanism for the released child and/or individual/program to whom the child is being released to be able to pay for any subsequent refills so that medications aren’t discontinued due to cost? Y__ N__ why not? [text] Please specify because if the child only gets a 30-day supply of medication, they need to be able to immediately refill those medications. PENDING LAB RESULTS Are there pending lab results, imaging studies or missing health records? N__ Y__, complete table below:
If yes, to whom and where should the results/records be mailed when available? [text] Name: [text] Physical address: [text] Address: [text] City: [text] State: [text] Zip Code: [text]
PARENTING CHILDREN Is the subject child a parent of a child in ORR care? Y__ N__ If the child is a parent of a child in ORR care, the Discharge Plan must include a Medicaid application for the child, if they are eligible (a US-born child of an unaccompanied child, must have a Medicaid application).
Is the subject child (or any of their children) eligible for health insurance (e.g., government-sponsored insurance, private insurance plan, charitable care) after discharge from ORR care? Y__ N__ Case managers must review a child's immigration status during the insurance review. If the child has a pending lawful immigration relief (asylum application, SIJ, etc.) and Medicaid eligibility requirements for a state.
If yes, did the Case Manager assist the subject child in applying for health insurance? Y__ N__, why not? [text] If yes, has the Case Manager researched these requirements and provided the child with clear instructions on how to establish residency upon release or age out, for the purposes of enrollment in health insurance? Y__ N__, why not? [text] If yes, enter the instructions provided to the child: [text]
|
Behavioral Health Support Summary |
This section should be completed in collaboration with the child so they may reference it to advocate for themselves. The child should be encouraged to reflect on their transition into ORR and identify the skills and supports that help them cope. Do not include any information about Child-Level Events.
List coping skills that the child can use in challenging situations: [text]
List any resources the child may need to implement their coping skills: [text]
List ways in which the child can access support to address their needs: [text] |
Summary of Strengths and Life Skills |
Summary of life skills developed in home country, on journey, previously in ORR care, or at current provider: [text] |
PART 2: POST-DISCHARGE PLAN
Share Part 2 with individual or agency receiving the unaccompanied child (or former UC) with child’s consent.
Placement Information After Discharge |
ORR’s recommended discharge option is: [text]____________________________________________ Post-release services (PRS) provider (if known): PRS Provider Name: [text]_____________________________________________ PRS Case Manager’s Name: [text]_____________________________________________ PRS Case Manager’s Contact Info: [text]________________________________________
Is the child being released to family or unrelated adult individuals who were identified as potential sponsors but did not complete the sponsorship process? Y__ N__ ORR wants to ensure the exiting adult is going to an individual who can help them meet their needs. Has the family or individual been flagged in the UC Portal? Y__ N__ Will the child be going to a family or individual who has been denied? Y__ N__ If yes, explain [text]____________________________________________
Individual/program name who will receive the released child: [text]______________________________________________________________________________
Does the child prefer a different placement than ORR’s recommendation Y__ N__ If yes, specify child’s preference: [text]________________________________________________________
URM PROGRAM Was there a referral to the URM program? Y__ N__ Through which umbrella organization is the child being placed, if applicable? [LIRS or USCCB or other] If Other, Specify: Was placement offered in the URM program? Y__ N__ Which URM program placed the child? [dropdown of URM providers]
PROGRAM INFORMATION Some examples of a program that a child may be released to include, but are not limited to, a URM Program, a domestic foster care agency, a youth shelter, a refugee resettlement agency, etc. Program Name:[text]_____________________________________ Address:[text]_____________________________________ City:[text]_____________________________________ State:[text]_____________________________________ Zip Code:[text]_____________________________________ Phone Number:[text]________________________________________ Other contact information for the program as applicable: [text]_____________ Is the program able to care for and shelter the released child without UC Program funding? Y__ N__ Is program appropriate and safe for the child?:[text]_____________________________________
AGE OUT CASES Has DHS ICE FOJC confirmed that they will release the child on their own recognizance? Y__ N__ Was this confirmation received in writing? Y__ N__ If no, continue seeking to obtain written confirmation from the DHS ICE FOJC, even if past the two weeks prior to 18th birthday Has the child been referred to ICE’s Young Adult Case Management Program (YACMP)? Y__ N__
Exiting adult who is being released to an individual: ORR wants to ensure the exiting adult is going to an individual who can help them meet their needs. Do not include the immigration status of individuals to whom the child may be released. What is the child’s relationship to the exiting adult? [text]_____________ Individual’s contact information: Name:[text]_____________________________________ Address:[text]_____________________________________ City:[text]_____________________________________ State:[dropdown]_____________________________________ Zip Code:[text]_____________________________________ Phone Number:[text]________________________________________ Other contact information for the individual as applicable: [text]_____________ Does the individual understand and agree to being financially responsible for caring for and housing the exiting adult? Y__ N__ Have safety concerns been identified as related to the individual? Y__ N__ If yes, has program provided safety planning around the safety concern? Y__ N__ Is the individual’s identity verified? Y__ N__ Did the case manager check if the sponsor was flagged or denied? Y__ N__
For a child who is aging out and being released to a program: Did the case manager contact local youth shelters, homeless shelters, or other licensed facilities licensed to care for young adults? Y__ N__ The case manager should arrange for the orderly discharge and transport of the child to the program.
REFUGEE BENEFITS ELIGIBILITY For children who are aging out OR being discharged to sponsors AND who are eligible for refugee benefits (e.g., children with OTIP eligibility letters, Afghan and Ukrainian parolees, Cuban/Haitian entrants, and asylees), was a connection with a refugee benefit provider made for post-release support and planning? Y__ N__ For children eligible for refugee benefits (e.g., children with OTIP eligibility letters, Afghan and Ukrainian parolees, Cuban/Haitian entrants, and asylees), was a connection with a refugee benefit provider made between the FFS and the Division of Refugee Services Preferred Communities staff? For more information on eligibility and documentation requirements for refugee benefits and services, see ORR PL 16-01. If you are unsure if this child is eligible for benefits, please email RefugeeEligibility@acf.hhs.gov.
TRAFFICKING CONCERNS For children with identified trafficking concerns, has a referral been made to OTIP prior to the child’s 18th birthday? Y__ N__ If no, submit the referral to OTIP here: https://shepherd.otip.acf.hhs.gov/ If yes, has the child received their interim assistance letter or eligibility letter while in care Y__ N__ If the child received interim assistance or eligibility letters, does the child have the original letter (not just a copy) as well as related OTIP benefits and resources in their discharge packet upon release? Y__ N__ Ensure
that the child is connected to a Trafficking Victim Assistance
Program (TVAP) case manager.
Please
contact TVAP@uscrimail.org
for any other questions. |
Financial Plan |
Skip if going to URM
Describe the current financial plan that supports the child upon discharge: [text] |
Education and Career Plan |
Skip if going to URM
Current school information (if applicable): Name: [text] Address: [text] City: [text] State: [text] Zip Code: [text] Date of Enrollment: [date format XX/XX/XXXX] Grade: [text] Extracurricular Activities: [text] Please be sure to include any transcripts, language competency testing results, placement results or High School Diploma upon discharge.
Was the child instructed on how to enroll in local school after they leave ORR care? Y__ N__ This assistance can be through the refugee resettlement preferred communities program for eligible former unaccompanied children. Who was the child told who to reach out to if they run into issues with enrollment (e.g., ORR National Call Center)? Y__N__
Future school information (if applicable) Name: [text] Address: [text] City: [text] State: [text] Zip Code: [text] Recommended extracurricular activities: [text] Future career intentions: [text] Career supports are available through the refugee program for eligible former unaccompanied children. Educational Plan and Goals: Education support is available through the refugee program for eligible former unaccompanied children. [text]
|
Community Resources Plan |
Skip if going to URM
Community resources and supports in the receiving community (i.e., Social Services, Transportation Access, Legal Clinics, English classes) Community resources and supports are available through the refugee program for eligible released . [text] |
Residential Plan |
Skip if going to URM
Describe the residential plan should the child age out of the program (this is NOT for age redeterminations, see the UC Policy Guide Section 1.6 for age redeterminations): [text]
Describe the future residential plan should the child’s lawful immigration relief option change: [text]
|
PART 3: SIGNATURES
Share Part 3 with individual or agency receiving the unaccompanied child (or former UC) with child’s consent.
Signatures and Contributors |
Information on this Discharge Plan may not be shared, except with authorized individuals receiving the child after their release, with the child’s consent, see UC Policy Guide Section 5.6.2 Maintaining Case Files, UC Policy Guide Section 5.9.2 Protecting Confidentiality of Mental Health and Medical Records and UC Policy Guide Section 5.10 Information Sharing. For disclosure of medical and mental health information contained in this Discharge Plan, the child must provide consent, as indicated by their signature to this Discharge Plan, for the release of this information to the individual or program receiving the child. If the child does not consent to the release of this information, the care provider must redact medical and mental health information contained in this Discharge Plan in the copy provided to the receiving individual or program.
CHILD SIGNATURE – AGE OUT CASES ONLY
For Post-18 only, signature needed two weeks before child turns 18 years of age:
Child's name: [text]
Child’s signature: [text]
Date: [date format XX/XX/XXXX]
CHILD SIGNATURE – ALL CASES
For all Discharge Plans, signature needed within 24 hours of departure from UC Program:
Child's name: [text]
Child’s signature: [text]
Date: [date format XX/XX/XXXX]
If the child has any questions about this Discharge Plan, they should ask their case manager, clinician, attorney, or LSP to help them. Signing below indicates that the care provider staff has carefully reviewed the Discharge Plan with the child in the child’s preferred language.
CARE PROVIDER SIGNATURE
Care provider name: [text]
Care provider staff name: [text]
Care provider staff signature: [text]
Date: [date format XX/XX/XXXX]
Umbrella Organization (i.e., Resettlement Agency), if applicable: [text]
Umbrella Organization staff name: [text]
Umbrella Organization staff signature: [text]
Date: [date format XX/XX/XXXX]
FFS SIGNATURE
FFS name: [text]
FFS signature: [text]
Date: [date format XX/XX/XXXX]
INDIVIDUAL RECEIVING RELEASED CHILD
Complete if applicable:
For individuals receiving released children that cannot read, the Discharge Plan must be discussed with them verbally. For individuals receiving released children that do not read English, a translation in their preferred language must be provided.
Name: [text]
Signature: [text]
Date: [date format XX/XX/XXXX]
AGENCY/PROGRAM RECEIVING RELEASED CHILD
Complete if applicable:
Program name: [text]
Program staff name: [text]
Program staff signature: [text]
Date: [date format XX/XX/XXXX]
Discharge Plan Contributors |
DISCHARGE PLAN CONTRIBUTORS
List of other people who assisted in the development of this plan (For example, LSPs, Attorneys of Record, Child Advocates, parents and/or legal guardians in home country)
Name: [text] Title: [text] Date: [date format XX/XX/XXXX]
Name: [text] Title: [text] Date: [date format XX/XX/XXXX]
Name: [text] Title: [text] Date: [date format XX/XX/XXXX]
Name: [text] Title: [text] Date: [date format XX/XX/XXXX]
THE
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF
PUBLIC BURDEN: The purpose of this information collection is to
allow ORR to create a discharge plan for children who are not
likely to be released to a sponsor that addresses the child’s
individual needs.. Public reporting burden for this collection of
information is estimated to average 2 hours per response, including
the time for reviewing instructions, gathering and maintaining the
data needed, and reviewing the collection of information. This is a
mandatory collection of information (Homeland Security Act, 6
U.S.C. 279). An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information subject to
the requirements of the Paperwork Reduction Act of 1995, unless it
displays a currently valid OMB control number. If you have any
comments on this collection of information please contact
UCPolicy@acf.hhs.gov.
R-9
| Version 1 Page
Revised MM/DD/20YY
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Julie Hutton |
| File Modified | 0000-00-00 |
| File Created | 2024-07-29 |
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