Placement Exception Request
Date:
Foster Parent Name:
Date:
Foster Parent Name:County of Residence:
DCBS HomeService Region:
PCP Home Name:
This Section Applies to DCBS Resource Homes Only
Type of Exception (check all that apply):
A Resource Home with more than five (5) children, including the foster parent's own children, that provides Basic or Advanced care.
A Resource Home with more than two (2) children under age two (2), including the foster parent's own children.
Medically Fragile
A Resource Home with more than four (4) children, including the foster parent's own children, that provides Medically Fragile care.
A one (1) parent Medically Fragile Resource Home caring for more than one (1) Medically Fragile child.
A two (2) parent Medically Fragile Resource Home caring for more than two (2) Medically Fragile child.
Placing a medically fragile child in a placement other than an approved medically fragile home.
Specialized Medically Fragile
A Resource Home with more than four (4) children, including the foster parent's own children, that provides Specialized Medically Fragile care.
A one (1) parent Specialized Medically Fragile Resource Home caring for more than one (1) Specialized Medically Fragile child.
A two (2) parent Medically Fragile Resource Home caring for more than two (2) Specialized Medically Fragile children.
Care Plus
A Resource Home with more than four (4) children, including the foster parent's own children, that provides Care Plus care.
A one (1) parent Care Plus Resource Home caring for more than one (1) Care Plus child.
A two (2) parent Care Plus Resource Home caring for more than two (2) Care Plus children.
This Section Applies to Private Child Placing (PCP) Foster Homes Only
Type of Exception (check all that apply):
A Foster Home that cares for children committed to the cabinet with more than five (5) children, including the foster parent's own children. (Check this box when requesting to exceed five (5) children in a home, if there are any DCBS committed children in that home).
A Foster Home with more than two (2) children under age two (2), including the foster parent's own children.
Therapeutic
A Therapeutic Foster Home that cares for a child in the custody of the cabinet, with more than four (4) children including the foster parent's own children.
A Therapeutic Foster Home that cares for a child in the custody of the cabinet, with more than two (2) Therapeutic foster care children.
Medically Fragile
A Foster Home with more than four (4) children, including the foster parent's own children, that provides Medically Fragile care.
A one (1) parent Medically Fragile Foster Home caring for more than one (1) Medically Fragile child.
A two (2) parent Medically Fragile Foster Home caring for more than two (2) Medically Fragile children.
Placing a Medically Fragile child in a placement other than an approved Medically Fragile home.
A Foster Home with more than four (4) children, with two (2) or more being Therapeutic Medically Fragile
Reason for the Exception:
To accommodate a sibling group
A therapeutic basis exists for the placement
Placing a Medically Fragile child in a placement other than an approved Medically Fragile home.
1. Provide a clear description of why an exception is requested:______
______
______
______
2. If the exception for placing aMedically Fragile child in a placement other than an approved Medically Fragile home;
answer the following:
a. Qualifications of foster parents. ______
______
______
b. Type of training the foster parents have received in order to care for this child, i.e., hospital staff, home health, previous foster parent. ______
______
______
c. Date when the foster parents will complete DCBS Medically Fragile foster care training. ______
d. Community supports/resources (home health referral, consultation with Commission for Children with Special Needs nurse, foster parent support group) in place. ______
______
e. PCC staff person trained to support foster parent. ______
f. Why this placement was identified as the best placement available to meet this child's needs. ______
______
______
______
______
3. Attach supporting documentation including medical and/or therapeutic information.
DPP-112A
(R. 02/08)
922 KAR 1:350
Page 1 of 3
Placement Exception Request
This Section Applies to DCBS Resource Homes Only______
Requesting Supervisor Name (Please Print) (County) Requesting Supervisor Signature Date
______
SRA of Receiving Region(Please Print) SRA of Receiving RegionSignature Date
APPROVED DENIED
If not the Region of case origin, approval for exceptions must also be granted by the SRA or designee of the Region carrying the case.
______
Approval Date SRA(s) or designee(s) of Region carrying the case(Please Print)
______
Director Signature Date
Signature of Protection and Permanency Director is required for Medically Fragile children placed in a home not
approved for Medically Fragile children.
This Section Applies to PCP Foster Homes Only
The SRA or designee, ______, was consulted on ______(MM/DD/YY)
______
Requesting Supervisor Name (Please Print) (County) Requesting Supervisor Signature Date
APPROVED DENIED
______
Program/Treatment DirectorName (Please Print) Program/Treatment Director Signature Date
______For a foster home that:
Director Signature Date a. Cares for a child in the custody of the cabinet; or
Signature of Protection and Permanency Director is b. Exceeds the number of children in a Medically
required for Medically Fragile children placed in a home not Fragile foster home in a situation other than the need
approved for Medically Fragile children to accommodate a sibling group;
The Program or Treatment Director consults with the
SRA in the Region where the foster home is located to
determine if the exception is in the best interest of the
child prior to approval/denial of the exception request.
Upon approval, the agency submits the DPP-112B within ten (10) working days of placement to the SRA in the Region where the
home is located which clearly describes the additional supportive services provided to each child in placement to ensure stability
for all children in the home.
File completed DPP-112A and DPP-112B in the case file of the foster parent, as well as that of each child placed in the home.
DPP-112A
(R. 02/08)
922 KAR 1:350
Page 1 of 3