Therapeutic Foster Care Placement Agreement
1. Parties
Child’s Name:
Date of Birth:
Child ID/Case #:
Foster Parent(s) Name(s):
Foster Home Address:
Agency Name:
Agency Contact Person:
2. Placement Information
Placement Start Date:
Anticipated End Date:
Reason for Placement:
3. Roles and Responsibilities
Agency Responsibilities:
Foster Parent(s) Responsibilities:
Visitation Arrangements:
4. Services to be Provided
Service
Provider/Contact
Frequency
5. Medical and Educational Details
Primary Physician:
Current Medications:
School Name:
Special Education Needs:
6. Emergency Contact
Name:
Relationship:
Phone Number:
7. Additional Notes/Specific Requirements
Foster Parent Signature
Date
Agency Representative Signature
Date