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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

2-5-2018

Subchapter:

1

Forms

Issuance:

10.12

CP&P Form 10-12, Consent to Out-of-State Placement by Parent(s) or Legal Guardian

 

 

Click here to view, print, or complete the CP&P Form 10-12 on-line.

 

Click here to view, print, or complete this form in Spanish, CP&P Form 10-12(S).

 

Instructions                                     2-6-2006

 

PURPOSE AND USE

 

The consent is used to obtain approval from the parent or legal guardian to place a child in an out-of-state living situation approved by CP&P.

 

Although the child's placement out of home must be authorized by a court order (or by a signed residential placement agreement, CP&P Form 25-59, or a consent to independent living, CP&P Form 10-8, when appropriate), use CP&P Form 10-12 to document the parent's/legal guardian's continued involvement in planning for the child being placed with an out-of-state provider/program.

 

The form may be completed at a Family Team Meeting.

 

INSTRUCTION FOR COMPLETING THE FORM

 

This letter is prepared by the assigned Worker and signed by the Worker and the parent or legal guardian when an out-of-state placement is being planned. The consent is prepared in quadruplicate.

 

The Worker enters the appropriate names on the face of the form.

 

The parent or guardian signs the agreement in the space provided directly below the body of the form. The Worker identifies the person by crossing out the non-applicable designation or by underlining or circling the correct designation. The parent/guardian enters his or her home address and telephone number.

 

The consent is dated when the parent or guardian signs it.

 

The Worker prints his or her name, title, office telephone number and personal extension, and the name and address of the Local Office.

 

The Worker signs the form, and enters the CP&P case identification number at the bottom of the page.

 

DISTRIBUTION

 

Original          -           Child's case record

 

Copy               -           Parent or Guardian

 

Photo Copy   -           Family Team Meeting participant(s), when appropriate

 

Two Copies   -           CP&P Interstate Services Unit