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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

5-20-2013

Subchapter:

1

Forms

Issuance:

25.46

CP&P Form 25-46 Exceptional Placement/Funding Request

 

Click here to view, complete, or print the CP&P form 25-46, Exceptional Placement Agreement/Funding Request

 

WHEN TO USE IT

 

The Exceptional Placement/Funding Request, CP&P Form 25-46, is a template for on-line use. This form has instructions embedded into the text form fields for ease of completion. Complete this form whenever approval is needed for a child's admission or continued residence in an exceptional placement.

NOTE: The Worker must attach a cover memo to this form that includes: A brief case summary, applicable reports, evaluations, assessments, court orders, eligibility notices, and any other reports that support the need for exceptional placement.

 

HOW TO USE IT

 

The form is used to:

      Record initial information regarding social characteristics (e.g., birth date, sex);

      Record NJ SPIRIT case ID number, Medicaid number, and Local Office information;

      Record present placement data (e.g., type of placement, address, contact person, and a narrative, explaining why the placement is needed);

      Record referral efforts to date;

      Record whether the child is DDD eligible, the eligibility date, and DDD Worker and telephone number;

      Whether there is a CSOC rule-out letter;

      Record required funding data (e.g., CP&P board rate, special educational funding); indicate whether this request is specifically for services beyond age 21; and

      Record what the permanency plan is for the child.

 

TIPS FOR COMPLETING THE FORM

 

The form is completed on-line using the web-based Manual. The form has text boxes, with instructions, and check boxes to answer yes/no questions. Navigate the form by using the tab key between enabled fields. For fields that require narrative answers, type in needed text into the required fields.

I.         IDENTIFYING INFORMATION

Name: Enter the surname, given name and middle initial for the child.

Birth Date: Enter the month, day, and year of the child's birth.

Address: Enter the address of the family member who has custody.

NJ SPIRIT Number: Enter the NJS case identification number.

Medicaid Number: Enter the Medicaid number for the child.

Local Office Name: Enter the Local Office name.

Child Currently Resides: Use the check box provided to enter where the child currently resides.

Address: Enter the child's current address.

II.       NEW PLACEMENT INFORMATION

Facility Name: If the child's present placement is the home of a parent or resource parent, enter the surname and given name of the female head of the household. If the child's present placement is in an institution (e.g., shelter, hospital or detention center), group home, or residential facility, enter current name of the facility.

Address/Telephone Number/Contact Person: Enter the address, telephone number, and contact person's name.

Rationale for Exceptional Placement Request: Input data to fully explain the reason exceptional placement is needed for this child.

List Programs and Other Options that Rejected a Placement Request: List all facilities that rejected the child from admission into their facility.

III.      DDD Eligible

Use the tab key to access the appropriate box for response. Once the appropriate box has been selected, use the "mouse" to select.

Enter the DDD Worker's name and contact telephone number.

IV.      COST ANALYSIS

Enter the cost of the facility, and the per diem rate in the text form fields provided.

Check "yes" or "no," to indicate whether the child's school district will meet the education costs.

The Worker then enters the "total" support service costs into the text form field, and the cost per month in the next text form field. The Worker indicates, by selecting the appropriate check box, if this request is for a child beyond the age of 21.

V.        PERMANENCY PLAN

Enter the permanency plan in the space provided.

VI.    SIGNATURES

Specified staff sign the form, where indicated.

Forward original, signed form to Director's Office

Note: A copy of the fully completed and signed Form 25-46 must be returned to the Local Office..

 

DISTRIBUTION

Original          -     

CP&P Director's Office

Copy             - 

DCF Office of Accounting

Copy             - 

Area Director

Copy             - 

Local Office/Administrative Assistant

Copy             - 

Case Record